Insurance adjudication favoring prophylactic surgery in hereditary breast-ovarian cancer syndrome

Insurance payment to cover costs of prophylactic surgery is occasionally denied to patients who may be at inordinately high risk for hereditary cancer. We describe a 43-year-old woman from a hereditary breast-ovarian cancer (HBOC) family which showed linkage to BRCA1 and who was at inordinately high risk for cancer but who was denied insurance coverage for prophylactic oophorectomy, despite strong recommendations by her gynecologist and a cancer geneticist-medical oncologist. The insurance company claimed that the surgery was not medically necessary because the woman's condition (hereditary cancer predisposition) was not an illness. A summary judgment issued by the Douglas County (Nebraska) District Court ruled in favor of the denial decision of Blue Cross/Blue Shield. But on appeal, the Nebraska Supreme Court offered the conclusion that the patient did in fact require this prophylactic surgery and overruled the District Court's decision for denial. The litigation provides the basis for this case report and may provide a precedent for insurance coverage for patients at high risk for hereditary forms of cancer.