Summary
Risk-reducing mastectomy may be considered medically necessary for individuals at high risk of breast cancer, including those with lobular carcinoma in situ, a known BRCA1 or BRCA2 variant, another high-risk gene variant such as TP53, PTEN, CDH1, STK11 or PALB2, or chest radiotherapy before 30 years of age. It is considered investigational for all other indications, including contralateral risk-reducing mastectomy in individuals with breast cancer who do not meet high-risk criteria. On 10/01/2026 the code reference was updated to add ICD-10 diagnosis codes QA1.790, QA1.791 and QA1.792.
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What to do
Action · 4 steps
01Already effective 10/01/2026: Billing team should check that the ICD-10 diagnosis codes QA1.790 (familial cancer syndrome with pathogenic BRCA1 mutation), QA1.791 (familial cancer syndrome with pathogenic BRCA2 mutation) and QA1.792 (Li Fraumeni syndrome) are among the covered diagnosis codes listed in the code reference when the claim is for risk-reducing mastectomy.
02Before billing, confirm the record documents high-risk criteria from the policy, because BCBSMS makes no payment for services not documented to be medically necessary.
03Contralateral risk-reducing mastectomy for individuals with breast cancer who do not meet high-risk criteria is investigational.
04Check current applicability with the payer before billing, since this date has passed.
Codes mentioned
19303D05.00D05.02N62Z15.01Z40.01Z80.3Z80.41Z80.8Z85.3
Original notice
Risk-Reducing Mastectomy
bcbsms.com · Always check the source before changing claims.
Related changes
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