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| Medical Policy: | X-21-013 |
| Topic: | Mammography |
| Section: | Radiology |
| Effective Date: | January 1, 2018 |
| Issue Date: | January 1, 2018 |
| Last Reviewed: | November 2016 |
Screening mammography is an x-ray of the breast used to aid in the detection of breast cancer in those patients with no signs or symptoms of disease. Diagnostic mammography is an x-ray used to further evaluate a finding in a screening mammography or used when a patient has other signs or symptoms or a history of cancer. Digital Breast Tomosynthesis (DBT) is a three dimensional view of the breast using x-ray technology, where the x-ray tube moves in an arc around the stabilized breast, and these images (slices) are then sent to a computer to produce the three dimensional image. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Screening Mammography
Payment will be made for one screening mammography including computer-aided detection (CAD) OR screening mammography with digital breast tomosynthesis per calendar year for asymptomatic individuals with female anatomy forty (40) years of age or older.
Screening digital breast tomosynthesis (77063) should not be reported as a stand-alone code and be reported with the primary screening mammography procedure (77067). When 77063 is reported without the appropriate screening mammography code, the add on code of 77063 will deny.
Self-referred screening mammograms for individuals with female anatomy under age forty (40) are not covered.
Prior to rendering the DBT service the following requirements for member safety, education and informed choice must be met:
- Provide educational materials to the patient outlining the study options so an informed decision can be made by the patient.
- Inform the patient of additional radiation exposure when both a 2-D mammography and 3-D DBT are performed.
Diagnostic Mammography
Diagnostic mammograms are covered according to a member’s individual or group customer benefits, that includes standard diagnostic mammography and diagnostic digital breast tomosynthesis.
If reporting the HCPCS II code for diagnostic digital breast tomosynthesis (G0279), it should be reported separately with the appropriate diagnostic primary mammogram service code. Procedure code, G0279, is an add on code.
| Professional Statements and Societal Positions |
American Cancer Society Guidelines for Breast Cancer Screening (2015). Women at Average Risk: Women at average risk should begin annual mammography at age 45. Older Women: Screening decisions in older women should be individualized by considering the potential benefits and risks of mammography in the context of current health status and estimated life expectancy. Women at Increased Risk: Women at increased risk of breast cancer might benefit from additional screening strategies beyond those offered to women of average risk, such as earlier initiation of screening, shorter screening intervals, or the addition of screening modalities other than mammography and physical examination, such as ultrasound or magnetic resonance imaging. However, the evidence currently available is insufficient to justify recommendations for any of these screening approaches. American College of Radiology (ACR). ACR Statement on Breast Tomosynthesis, November 24, 2014. As this technology is used in clinical practice, we anticipate that further studies will clarify its impact on long-term clinical outcomes, including reduced mortality. It will also be important to further elucidate which subgroups of women might benefit most from these exams (by age, breast density, frequency of examination, etc.). To be clear: tomosynthesis is no longer investigational. Tomosynthesis has been shown to improve key screening parameters compared to digital mammography. While the College encourages more studies to clarify the clinical role(s) of tomosynthesis and its long-term outcomes, it is clear that tomosynthesis represents an advance in breast imaging. American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Advisory on Breast Cancer Screening, April 20, 2015. Further study will be necessary to confirm whether digital mammography with tomosynthesis is a cost-effective approach capable of replacing digital mammography alone as the first-line screening modality of choice for breast cancer screening. National Comprehensive Care Network (NCCN). Breast Cancer Screening and Diagnosis. Version 1.2015 Breast Screening Considerations: Early studies show promise for tomosynthesis mammography. Several studies show a combination of digital mammography and tomosynthesis resulted in improved cancer detection and decreased call back rates. Of note, most studies used double the dose of radiation. The radiation dose can be minimized by synthetic 2-D reconstruction. Definitive studies are still pending. United States Preventive Task Force (USPSTF) Breast Cancer: Screening Draft Recommendation Statement April 20, 2015. For all women the USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of tomosynthesis (3-D mammography) as a screening modality for breast cancer. “I” rating indicating the evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. |
| Place of Service: Outpatient |
Mammography is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
A network provider can bill the member for the non-covered service.
When a screening digital breast tomosynthesis (77063) is reported without the appropriate screening mammography procedure code (77067), it will be denied as not covered, and non-billable.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
10/2015, Digital Breast Tomosynthesis Coverage Update
 |
This policy is intended to document those medical guidelines used by Highmark Blue Cross Blue Shield Delaware for the purpose of coverage and reimbursement determinations under Highmark Blue Cross Blue Shield Delaware health benefit plans. These guidelines are appropriate for the majority of individuals with a particular disease, illness, or condition; however, each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Highmark Blue Cross Blue Shield Delaware retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark Blue Cross Blue Shield Delaware. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
