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.
POLICY
Mammography screening for women at average risk 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 will be considered medically appropriate if any of the following criteria are met:
A baseline mammogram for women thirty-five (35) to forty (40) years of age (See Additional Information); and
Annual mammogram for women ages 40 and over
Women who are at higher risk should seek expert medical advice about when to begin screening and in determining the frequency. Mammograms that do not fall within the above categories are covered if there is increased risk of breast cancer, such as:
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%).
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
Agency for Healthcare Research & Quality. (2002, February). U.S. Preventive Services Task Force. Screening for breast cancer. Recommendations and rationale. Retrieved June 25, 2007 from http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm.
Agency for Healthcare Research & Quality. (2003, November). U.S. Preventive Services Task Force. The cost-effectiveness of screening mammography beyond age 65: A systematic review for the U.S. Preventive Services Task Force. Retrieved June 21, 2007 from http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm.
American Cancer Society. (2007). ACS guidelines for the early detection of cancer. Retrieved June 22, 2007 from http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp?sitearea=PED&viewmode=print&.
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 College of Obstetricians and Gynecologists. (2003, April). ACOG Practice Bulletin: Breast cancer screening. Retrieved September 16, 2005 from http://www.acog.com/publications/committee_opinions/bco185.htm.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2006). Computer-aided detection in conjunction with digitized screen-film mammography or full-field digital mammography (6.01.39). Retrieved June 5, 2007 from BlueWeb.
BlueCross BlueShield Association. Medical Policy Reference Manual. (5:2005). Full-field digital mammography (6.01.34). Retrieved June 5, 2007 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]. (2007, April). Mammograms (NCD 220.4, p. 2-164, 2-165). St. Anthony Publishing.
ECRI Institute. Health Technology Information Service. TARGET. (2007, April). Full-field digital mammography for breast cancer screening. Retrieved June 19, 2007 from ECRI Institute.
ECRI Institute. Health Technology Information Service. TARGET. (2002, May). Computer-aided detection (CAD) for breast cancer screening (update in progress). Retrieved June 19, 2007 from ECRI Institute.
ECRI Institute. Health Technology Information Service. Windows on Medical Technology. (2002, October). Computer-aided detection in screening mammography. Retrieved June 19, 2007 from ECRI Institute.
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.
Farria, D. M., & Monsees, B. (2004). Screening mammography practice essentials. Radiologic Clinics of North America, 42 (5), 831-843.
Hayes. Medical Technology Directory. (2002, February). Screening mammography for women at average risk for breast cancer. Retrieved June 19, 2007 from www.Hayesinc.com/subscribers.
Hayes. Medical Technology Directory. (2003, February). Computer-aided detection for screening mammography. Retrieved June 19, 2007 from www.Hayesinc.com/subscribers.
Institute for Clinical Systems Improvement. (2004, April). Technology assessment report #84. Computer aided detection of breast cancer. Retrieved June 21, 2007 from http://www.icsi.org/technology_assessment_reports_-_active/ta_computer_aided_detection_of_breast_cancer.html.
Lewin, J. M., D’Orsi, C. J., & Hendrick, R. E. (2004). Digital mammography. Radiologic Clinics of North America, 42 (5), 871-874.
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.
National Guideline Clearinghouse. (2003, April). Breast cancer screening. Retrieved June 22, 2007 from http://www.guidelines.gov.
National Guideline Clearinghouse. (2003, July). ACS guidelines for breast cancer screening: Update 2003. Retrieved June 21, 2007 from http://www.guidelines.gov.
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.
The Technology Evaluation Center (2002, December). Computer-aided detection (CAD) in mammography (Vol. 17, No. 17). Chicago: BlueCross BlueShield Association.
U. S. Food and Drug Administration. (2004, July). Center for Devices and Radiological Health. New device approval. P030012. Retrieved June 19, 2007 from http://www.fda.gov/cdrh/PDF3/p030012.html.
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EFFECTIVE DATE |
7/26/2007 |
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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.
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