BlueCross BlueShield of Tennessee Medical Policy Manual

Mammography

DESCRIPTION

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.

POLICY

MEDICAL APPROPRIATENESS

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

Tenn. Code Ann. Ā§ 56-7-2502; Mammography Screening

(a) Any 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.

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The modified Gail model assesses risk for invasive breast cancer, accessible at http://www.cancer.gov/bcrisktool/.

SOURCES 

American Cancer Society. (2017). American Cancer Society recommendations for the early detection of breast cancer. Retrieved April 18, 2019 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. (2018, October). NCCN Clinical Practice Guidelines in Oncology (NCCN GuidelinesĀ®). Breast cancer screening and diagnosis. V.3.2018. Retrieved April 18, 2019 from the National Comprehensive Cancer Network.  

National Comprehensive Cancer Network. (2019, January). NCCN Clinical Practice Guidelines in Oncology (NCCN GuidelinesĀ®). Genetic/familial high-risk assessment: breast and ovarian. V.3.2019. Retrieved April 18, 2019 from National Comprehensive Cancer Network. 

National Institute for Health and Care Excellence. (2013). Familial breast cancer. Retrieved June 19, 2015 from www.nice.org.uk/guidance.

Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 25 Mandated Insurer or Plan Options: 56-7-2502. Mammography screening. Retrieved April 18, 2019 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. 

Winifred S. Hayes, Inc. Medical Technology Directory. (2015, December; last update search November 2018). Full-field digital mammography for breast cancer screening. Retrieved April 18, 2019 from http://www.hayesinc.com/subscribers. (63 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  12/1997

MOST RECENT REVIEW DATE:  5/9/2019  

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.