UM Guidelines
Mastectomy, Complete, with Tissue Flap Reconstruction

Inpatient and Surgical Care (ISC)

BCBST last reviewed January 30, 2021*

Added to Clinical Indications:

Procedure may be indicated for 1 or more of the following:
  • Subcutaneous or total (simple) mastectomy indicated for...
    • [Patient or provider preference over partial mastectomy]*
    • ...
    • Risk-reduction mastectomy (RRM) indicated...
      • Significantly elevated risk of breast cancer as indicated by...
        • [Lobular carcinoma in situ]*
        • ...


American Cancer Society. (2020). Mastectomy. Retrieved July 21, 2020 from

BlueCross BlueShield Association. Evidence Positioning System. (8:2019). Risk-reducing
mastectomy (7.01.09). Retrieved July 21, 2020 from
(21 articles and/or guidelines reviewed)

National Cancer Institute. (2020). Surgery to reduce the risk of breast cancer. Retrieved July 21,
2020 from


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