Diagnostic Mammography
A diagnostic mammogram (film or digital) is considered medically necessary under any of the following conditions:

1. The patient has a personal history of breast cancer.

2. The patient has distinct signs and symptoms for which a mammogram is indicated, such as but not limited to:

   1. breast mass or nodes
   2. painful or tender breasts
   3. change in the color, surface, size and/or shape of the breast, nipple or skin
   4. nipple discharge
   
   

3. Based on the patient's history and other significant factors, a mammogram is appropriate. Conditions such as, but not limited to, those listed below warrant the medical necessity for mammograms:

   1. metastases or nodes in areas of the body other than the breast but the primary site is unknown
   2. history or presence of endometrial cancer
   3. previous suspicious lesions or masses of the breast
   4. where evaluation by palpation is difficult because of large fatty breasts, augmented breasts, or implanted breasts

Fibrocystic disease, in and of itself, does not warrant medical necessity for a diagnostic mammogram. However, a patient diagnosed with fibrocystic disease and experiencing suspicious changes, signs or symptoms as specified in items #1 through #3 above would be eligible for a diagnostic mammogram (77055, 77056, G0204, or G0206, as appropriate).

Screening Mammography
Annual screening mammograms are a covered benefit. Mammograms for the routine screening of asymptomatic women, whether or not family members (e.g., mother, sister) have had breast cancer, or whether or not physician recommended, are considered screening (77057 or G0202).

Payment is made for one (1) routine screening mammogram per calendar year for asymptomatic women forty years of age or older.

Additionally, physician recommended mammograms (i.e., those that are prescribed by a physician) are covered for all other women (under age 40) regardless of the reason performed; this includes baseline mammograms and routine mammograms. Payment for physician recommended mammograms is not limited to one (1) per year. Coverage for screening mammograms is determined according to individual or group customer benefits.

Self-referred screening mammograms for women under age 40 are not covered.

Screening Mammography When Additional Views Are Needed
When a screening mammogram does not require additional views to establish a diagnosis (for example, a cluster of tumor microcalcifications), it is considered a screening mammogram. However, a screening mammogram may show a potential problem. Additional views may then be needed to clarify or confirm the suspicious lesion. 

When additional views are needed during a screening mammogram to diagnose or confirm a suspicious mammographic lesion, the service is considered a diagnostic mammogram and should be reported and processed as such, whether additional views are taken at the initial imaging session or on a different date of service. Since extra views were obtained to complete a single mammography study, they are not considered or paid as a separate service.

Mammography and Computer-Aided Detection (CAD)
Procedure codes 77051 and 77052 represent computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of the film radiographic images for diagnostic and screening mammographies. Both codes 77051 and 77052 are designated as "add-on" codes. Add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone service.

• Code 77051 should always be reported with the appropriate diagnostic mammography code 77055, 77056, G0204, or G0206, as appropriate.
  
  
• Code 77052 should always be reported with the appropriate screening mammography code 77057 or G0202, as appropriate.

Code 77051 or 77052 should be reported on the same claim with the primary mammography procedure with which it is performed. When reported without the appropriate mammography code, the add-on codes will be denied. A participating, preferred, or network provider cannot bill the member for the denied service in this situation.

Refer to Medical Policy Bulletin X-19 for information on xeroradiography (xeromammography).

NOTE:

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.

Under Preventive care, adult, both Standard and Basic option will cover Breast cancer screening (routine mammograms).