Mammography is a type of x-ray of the breast used to detect breast cancer. 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 diagnosis 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: Individuals who are at higher risk should seek medical advice about when to begin screening and in determining the frequency.
Mammography is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Mammography with or without computer-aided detection (CAD) is considered medically appropriate if ANY ONE of the following are met:
Women at average risk for ANY ONE of the following:
A baseline screening mammogram for women thirty-five (35) to forty (40) years of age
Annual screening mammogram for women ages 40 and over
Women at increased risk with 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
Known BRCA1, BRCA2, PALB2, CDH1 or NF1 gene mutation
First-degree relative (parent, brother, sister, or child) with a BRCA1, BRCA2, or PALB2 gene mutation and have not had genetic testing themselves
Lifetime risk of breast cancer of 15% to 20% according to risk assessment tools that are based mainly on family history ( BCRISKTOOL or BOADICEA [breast and ovarian analysis of disease incidence and carrier estimation algorithm] assessment tool)
Personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS) atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
Prior thoracic radiation therapy between 10 to 30 years of age
Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome or have first degree relatives with one of these syndromes
Extremely dense breasts or unevenly dense breast
Men at 40 years of age with increased risk with ANY ONE of the following:
Family history of hereditary breast and ovarian cancer (HBOC)
Gynecomastia or parenchymal/glandular breast density on baseline study
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
Tenn. Code Ann. § 56-7-2502; Mammography Screening
individual, franchise, blanket or group health insurance policy, medical
service plan, contract, hospital service corporation contract, hospital
and medical service corporation contract, fraternal benefit society, or
health maintenance organization that provides coverage for surgical services
for a mastectomy, and that is delivered, issued for delivery, amended
or renewed on or after July 1, 1989, shall also provide coverage for mammography
screening performed on dedicated equipment for diagnostic purposes on
referral by a patient's physician according to the following guidelines:
(1) A baseline mammogram for women thirty-five (35) to forty (40) years of age;
(2) A mammogram every two (2) years, or more frequently based on the recommendation of the woman's physician, for women forty (40) to fifty (50) years of age; and
(3) A mammogram every year for women fifty (50) years of age and over.
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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.
The modified Gail model assesses risk for invasive breast cancer, accessible at http://www.cancer.gov/bcrisktool/.
American Cancer Society. (2020). American Cancer Society recommendations for the early detection of breast cancer. Retrieved March 16, 2020 from http://www.cancer.org.
Centers for Medicare & Medicaid Services. CMS.gov. (May, 1978). National Coverage Determination: NCD for mammograms (220.4). Retrieved June 14, 2016 from http://www.cms.gov.
National Comprehensive Cancer Network. (2020, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast cancer screening and diagnosis. V.1.2020. Retrieved February 2, 2021 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2021, November). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Genetic/familial high-risk assessment: breast and ovarian. V.2.2021. Retrieved February 2, 2021 from National Comprehensive Cancer Network.
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 25 Mandated Insurer or Plan Options: 56-7-2502. Mammography screening. Retrieved February 2, 2021 from http://www.lexisnexis.com.
U. S. Preventive Services Task Force. (2016, February). Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Retrieved June 14, 2016 from http://www.guideline.gov.
ORIGINAL EFFECTIVE DATE: 12/1997
MOST RECENT REVIEW DATE: 3/11/2021
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.