Health Care Coverage for Preventive Surgery

Prophylactic (preventive) treatment is expensive because of all of the surgery, anesthesia, nursing, and hospital costs. Most people cannot afford to pay for this on their own — nor should they have to. Many insurance companies will pay without any special explanations. But in some cases you might have to put together supporting documentation to get your insurance company to pay. Get letters of support from your primary care doctor and your surgeon that spell out your reasons for taking this big step.

This gets complicated if you are basing your decision for prophylactic surgery on the results of an abnormal BRCA1 or BRCA2 test — AND if you want to keep this information completely private. Some doctors are able to persuade medical insurance companies to cover the cost of prophylactic surgery based on family history alone — with no mention of genetic test results. In other situations, you may need genetic information that requires input from your gene-testing center, genetic counselor, and oncologist to win coverage.

Some health insurance companies may view this surgery as “elective,” meaning they don't think it's 100% essential for your health. In this case, it might be harder to get them to pay for it. Each application will likely be judged separately. Prepare for an active defense with your doctor's help. Surgeons who specialize in breast and ovary surgery usually have the most experience in getting the cost of the procedures covered by insurance.