Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Risk-reducing bilateral mastectomy for people with other risk factors
Document related concepts
no text concepts found
Transcript
Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 HEALTH INSURER 123 Insurance Way Anywhere, IL 012345 DATE RE: Insured: Claimant: Claim # XXXXXXXXXXX NAME (ID# XXXXXXXXXXX) NAME (DOB Mo-Day-Year) To Whom It May Concern: I am writing to appeal the decision to deny coverage of my prophylactic bilateral mastectomy by [Health Plan Name]. Genetic testing confirmed that I carry a mutation in the XXX [insert CDH1, PTEN or TP53 as appropriate] gene which puts me at significantly increased risk of breast and ovarian cancer. My cancer risk is similar to that of a BRCA mutation carrier. The U.S. Preventive Services Task Force (USPSTF) BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing guidelines published in December 2013, give a “Grade: B” to screening women who may be at high risk of breast, ovarian, tubal, or peritoneal cancer. “Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.”1 The clinical value of identifying people with a genetic mutation placing them at high risk of cancer lies in an individual’s ability to access appropriate, evidence-based screening and preventive services that lower the risk for breast or ovarian cancer. As such, USPSTF guidelines indicate that “risk-reducing surgery (e.g. mastectomy or salpingo-oophorectomy) is a recommended intervention women at high risk of breast cancer [Exhibit A] and state the benefits of risk-reducing surgery. [Exhibit B] The National Cancer Institute says, “Bilateral prophylactic mastectomy has been shown to reduce the risk of breast cancer by at least 95 percent in women who have a deleterious (diseasecausing) mutation.”2 While the USPSTF has yet to publish guidelines for the full range of hereditary cancer mutations, there is broad consensus among clinical organizations about the benefits of riskreducing surgery in women with genetic mutations linked to hereditary breast cancer. The National Comprehensive Cancer Network (NCCN) [Exhibit C], American Congress of Obstetricians and Gynecologists (ACOG) [Exhibit D], Society of Surgical Oncology [Exhibit E], and American Society of Clinical Oncology (ASCO) [Exhibit F] all recognize that a high penetrance mutation justifies prophylactic bilateral mastectomy, also known as a risk-reducing mastectomy (RRM). Aetna insurance considers “prophylactic mastectomy medically necessary for reduction of risk of breast cancer” in high-risk women “who carry a genetic mutation in the TP53 or PTEN genes” or “who possess BRCA1 or BRCA2 mutations.”3 Most major health insurers have similar policies. No woman wants to undergo a double mastectomy but given my high risk of cancer, and the evidence of medical necessity, my medical team and I respectfully request that you reverse the denial of coverage for this surgery. Thank you for your consideration. Your prompt attention to this appeal is greatly appreciated. Sincerely, [Signature] 1 BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing, December 2013 (http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/brca-related-cancer-risk-assessmentgenetic-counseling-and-genetic-testing) 2 Surgery to Reduce the Risk of Breast Cancer (http://www.cancer.gov/types/breast/risk-reducing-surgery-fact-sheet) 3 BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy (http://www.aetna.com/cpb/medical/data/200_299/0227.html) Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit A Source: http://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/brca-related-cancerrisk-assessment-genetic-counseling-and-genetic-testing Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit B Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit C Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit C (continued) Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit D Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit D (continued) Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit E Sample Appeal Letter for Prophylactic Mastectomy Unaffected Carrier - CDH1, PTEN or TP53 Exhibit F
