Fortunately, Angelina Jolie Isn't On Medicare

Margaret Dick Tocknell, for HealthLeaders Media , May 22, 2013

Even signing up for a Medicare Advantage plan from a private payer could be an option for Medicare-eligible women to gain BRCA coverage. Many commercial insurers apply their BRCA and prophylactic mastectomy criteria to their Medicare Advantage plans as well despite the lack of a definitive CMS policy.

The weak link is Medicare.

As for large private payers, most not only cover BRCA and prophylactic mastectomies, they are explicit about their coverage criteria. (A word of caution: Just because coverage is offered by payers does not mean that every employer will elect to include it.)

Aetna's approach is typical. A 23-page clinical policy bulletin details the high-risk indicators that must be met to deem that testing, and then the procedure itself are medically necessary.

To develop their coverage criteria, insurers have turned to guidelines from the American College of Obstetricians and Gynecologists, the American College of Medical Genetics, and the U.S. Preventive Services Task Force among other groups and organizations. Among the high-risk indicators:

  • Women diagnosed with breast cancer at 45 years of age or younger
  • Two members of family diagnosed with breast cancer under age 50 or ovarian cancer at any age
  • Close male blood relative with breast cancer
  • Women without a personal history of breast cancer with three or more close blood relatives on the same side of the family with breast cancer.
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Comments are moderated. Please be patient.

4 comments on "Fortunately, Angelina Jolie Isn't On Medicare"

CPutnam (9/17/2014 at 9:42 PM)
Just like a man to comment on breasts. My sister has had breast cancer. Is a BRCA carrier. She only has Medicare to rely on. So they would rather she get cancer before they help her. ? Asinine.

Laurie (6/1/2013 at 6:30 PM)
@Grandma, I believe age is a risk factor for breast cancer in general. But, hereditary cancer is a different category [INVALID] tied to cancer at a young age (e.g., like Jolie's mother). This could be a legitimate reason why Medicare doesn't cover the prophylactic measures for BRCA gene positive women [INVALID] they should be done long before she reaches Medicare age, and, presumably, she's also likely to get that type of breast cancer before then as well.

Grandma (5/27/2013 at 12:25 AM)
Donald Stumpp, are you a doctor? Obviously not! The chances of a woman getting breast cancer gets greater as she gets older. Who are you to say Medicare shouldn't pay for the surgery? That is the insurance plan we have paid into all our lives and still pay a monthy premium for it.




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