Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy (CPB 0227, reviewed 2026-04-14)

By April 14, 2026: Billing and authorization teams must implement the following: (1) Update prior authorization workflows to require documentation that prophylactic mastectomy or oophorectomy patients meet one of the specific medical necessity criteria listed in the policy (e.g., BRCA1/BRCA2 mutations, family history, prior breast cancer diagnosis). (2) Establish denial protocols for non-covered procedures including prophylactic mastectomy for women with CHEK2 mutations, prophylactic mastectomy for men with BRCA mutations, and multigene panel tests with RNA analysis or polygenic risk scores. (3) Configure billing system to limit multigene panel testing coverage to once per lifetime per patient and to deny testing for individuals under 18 years of age. (4) Train billing staff to verify genetic counselor or physician documentation of hereditary cancer syndromes and family pedigree analysis before approving oophorectomy claims. (5) Update claim submission templates to require specification of which medical necessity criterion the patient meets. Failure to obtain proper authorization or documentation will result in claim denials. Contact Aetna for specific CPT/HCPCS codes associated with these procedures if not already in system.