Dive Brief:
- Blue Cross Blue Shield of Massachusetts, the largest payer in the state, recently denied coverage to eight women seeking double mastectomies in cases where there was only cancer detected in one breast—a procedure that is commonly accepted to reduce the risks and stresses of a recurrence in the other breast.
- Following an inquiry by the Boston Globe, the insurer approved coverage for the eight women it had previously denied. It said the denials were a result of confusion caused by new language in their policies.
- The situation is highlighting concerns about who gets to decide what procedures are medically necessary, and how insurers will handle costly procedures such as these in the face of mounting pressures to control costs.
Dive Insight:
Insurers are in a delicate position as the ACA requires them to cover more while also managing costs.
"There are so many procedures and new technologies that are being recommended that it's difficult to decide what's appropriate for which patient," Prof. Wendy K. Mariner at Boston University School of Public Health told the Boston Globe.
Meanwhile, Blue Cross Blue Shield says it never intended to limit the number of patients receiving double mastectomies. The company told the Globe that changes to the language in their policies, which were meant to clarify their coverage information, ended up confusing patients, providers and their own claims personnel.
Eleven percent of women with cancer in one breast chose to have double mastectomies in 2011, a 2% increase from 1998. In addition, there appears to be public sentiment toward aggressive breast cancer prevention, highlighted by the so-called Angelina effect: More women are seeking genetic testing to weigh their risk of breast cancer and the potential benefit of a preemptive double mastectomy.