CommercialCoverageMedium impact
Risk-Reducing Mastectomy
Blue Cross & Blue Shield of Mississippi·MS · General Surgery, Plastic Surgery, OB-GYN +1 more·Medical Policy
We identified it
Jun 20, 2026
Summary
BCBSMS updated their risk-reducing mastectomy policy defining when bilateral or contralateral mastectomies are considered medically necessary versus investigational. The policy establishes specific high-risk criteria including BRCA1/BRCA2 variants, lobular carcinoma in situ, chest radiation before age 30, and other genetic conditions that qualify for coverage.
Action Required
Immediately: Review all pending and future risk-reducing mastectomy cases to ensure patients meet the high-risk criteria defined in policy A.7.01.09. Billing team must verify documentation includes specific risk factors (BRCA variants, lobular carcinoma in situ, chest radiation before age 30, or other qualifying genetic conditions) before submitting claims. Cases not meeting high-risk criteria will be considered investigational and likely denied.