Mammography Screening
DESCRIPTION
Mammography is an x-ray of the breast that can be used as a screening technique for the detection of unsuspected breast cancer and other diseases. Mammography is generally accepted as the best available method for detecting breast cancer in its earliest, nonpalpable stage, which is also the most curable state. It is also used as an aid in the diagnoses of palpable breast lesions and in determining the exact location for further studies and treatment.
Computer-aided detection (CAD) aids the radiologist in correctly identifying abnormalities on the mammogram and requires the use of a digital image. CAD can highlight suspicious regions on the mammogram for the radiologist to re-examine.
Note: Women who are at higher risk should seek expert medical advice about when to begin screening and in determining the frequency
POLICY
Mammography screening is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
See also: Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast
MEDICAL APPROPRIATENESS
Mammography screening for women will be considered medically appropriate with ANY ONE the following:
Women at average risk with ANY ONE the following:
A baseline mammogram for women thirty-five (35) to forty (40) years of age
Annual mammogram for women ages 40 and over
Women at high risk with the ANY ONE of the following:
Breast changes that persist, such as a lump, thickening, swelling, dimpling, skin irritation, distortion, retraction or scaliness of the nipple, nipple discharge, or a previous abnormal mammogram
Diagnosis of a breast disease that may predispose a woman to breast cancer
Family history of breast cancer (mother, daughter, sister), or having two or more close relatives, such as cousins, with history
Menopause at 55 years or older
No childbearing or late childbearing (age 30 or older at first birth)
Personal history of breast cancer
Personal history of two or more biopsies for benign breast disease
Start of menses at or before age 10
Unclear, difficult mammogram reading due to denseness (above 75%)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Current evidence suggests that mammography screening should begin at age 40. However, due to the Tennessee State legislative mandate, BlueCross BlueShield of Tennessee considers a baseline mammography to be appropriate for women between the ages of 35 and 40 years.
SOURCES
American Cancer Society. (2007). Mammograms and other breast imaging procedures. Retrieved June 21, 2007 from http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Mammography_and_other_Breast_Imaging_Procedures_5.asp.
American Cancer Society. (2009, May). ACS guidelines for the early detection of cancer. Retrieved February 8, 2010 from http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp?sitearea=PED&viewmode=print&.
American Congress of Obstetricians and Gynecologists. (2009, November). Interpreting the U. S. Preventive Services Task Force breast cancer screening recommendations for the general population. Retrieved February 8, 2010 from http://www.acog.org/from_home/Misc/uspstfInterpretation.cfm.
BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2008). Computer-aided detection in conjunction with digitized screen-film mammography or full-field digital mammography (6.01.39). Retrieved February 8, 2010 from BlueWeb.
BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2005). Full-field digital mammography (6.01.34). Retrieved February 8, 2010 from BlueWeb.
Chaudhry, R., Scheitel, S. M., McMurtry, E. K., Leutink, D. J., Cabanela, R. L., Naessens, J. M., et al. (2007). Web-based proactive system to improve breast cancer screening: A randomized controlled trial. Archives of Internal Medicine, 167 (6), 606-611. Abstract retrieved June 21, 2007 from PubMed database.
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Mammograms (NCD 220.4, p. 2-166). Ingenix.
Evans, A. J., Kutt, E., Record, C., Walter, M., & Moss, S. (2006). Radiological findings of screen-detected cancers in a multi-centre randomized, controlled trial of mammographic screening in women from age 40 to 48 years. Clinical Radiology, 61 (9), 784-788. Abstract retrieved June 21, 2007 from PubMed database.
Moss, S. M., Cuckle, H., Evans, A., Johns, L., Waller, M., Bobrow, L., et al. (2006). Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: A randomised controlled trial. Lancet, 368 (9552), 2053-2060. Abstract retrieved June 21, 2007 from PubMed database.
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 25 Mandated Insurer or Plan Options: 56-7-2502. Mammography screening. Retrieved June 12, 2007 from http://www.legislature.state.tn.us/sitemap.htm.
ORIGINAL EFFECTIVE DATE: 12/1997
MOST RECENT REVIEW DATE: 4/8/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.