Medical Policy Medical Policy
Policy Num: 06.001.006
Policy Name: Screening and Diagnostic Mammography
Policy ID: [06.001.006] [Ar / L / M+ / P-] [0.00.00]
Last Review: September 07, 2023
Next Review: Policy Archived
ARCHIVED
Related Policies: None
| Population Reference No. | Populations | Interventions | Comparators | Outcomes |
| 1 | Individuals: · Asymptomatic woman ages 50-74 | Interventions of interest are: · Screening mammography | Comparators of interest are: · Other diagnostic and screening imaging available | Relevant outcomes include: · Early detection · Improvement in the net health outcome |
| 2 | Individuals: · With signs and symptoms of breast disease, or personal history of breast cancer, or a personal history of biopsy-proven benign breast disease | Interventions of interest are: · DIagnostic mammography | Comparators of interest are: · Other diagnostic and screening imaging available | Relevant outcomes include: · Early detection · Improvement in the net health outcome |
Screening Mammogram
A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection breast cancer,and includes a physician’s interpretation of the results of the procedure.
For asymptomatic woman ages 50-74. Intervention of interest is Screening Mammography. Comparators of interest are other diagnostic and screening imaging available. Relevant outcomes include early detection and improvemnt of the net health outcome. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
Diagnostic Mammography
A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure.
For individuals with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease. Intervention of interest is Diagnostic Mammography. Comparators of interest are other diagnostic and screening imaging available. Relevant outcomes include early detection and improvemnt of the net health outcome. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
The objective of this evidence review is to determine whether the use of screening and diagnostic mammography improves the net health outcome in individuals being screened for breast cancer.
Screening Mammogram
A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection breast cancer,and includes a physician’s interpretation of the results of the procedure. A screening mammogram does not require a physician’s referral, however, detection of a radiographic abnormality, may prompt the interpreting radiologist to order additional views on the same day. When this is the case, the mammography is no longer considered to be a screening exam and should be reported as a diagnostic mammogram. Radiologists who order additional tests must refer back to the treating physician or qualified non-physician practitioner for his/her UPIN and report back to the treating physician the condition of the patient. No separate reimbursement will be made for additional views. The cost for additional views is included in the cost of the diagnostic mammography service. Screening mammogram(s) (digital and non-digital) for the following indications are allowed:
Diagnostic Mammography
A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure.
Diagnostic mammogram(s) are allowed for the following indications:
Diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease. These diagnoses should not, however, routinely warrant a diagnostic mammography.
A breast implant does not necessarily imply that a mammogram is diagnostic in nature. Although additional views may be needed, these additional views do not necessarily constitute a diagnostic mammogram, unless there are specific findings that require investigation.
A physician (or qualified non-physician practitioner) referral is required for diagnostic mammography. The patient must be under the care of the physician (or qualified non-physician practitioner) who orders the procedure. The order should specify the diagnosis prompting the referral for a diagnostic mammogram.
Diagnostic mammography should be performed under the direct, on-site supervision of an interpreting physician qualified in mammography. Diagnostic mammography may require that the performing radiologist review the history with the patient, review the prior mammograms, and perform an examination as part of the mammography. Also, the findings of the examination are typically discussed with the patient at the completion of the mammogram. Therefore, if telemammography is being used with digital diagnostic mammography, the radiologist need not be present for the mammography; however, he/she must be available to discuss the history with the patient, examine the patient, and discuss results of the findings of the examination with the patient within an acceptable period of time.
See codes section.
BlueCard/National Account Issues - N/A
Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.
N/A
N/A
Population Reference No. 1
For asymptomatic woman ages 50-74. Intervention of interest is Screening Mammography. Comparators of interest are other diagnostic and screening imaging available. Relevant outcomes include early detection and improvemnt of the net health outcome. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
| Population Reference No. 1 Policy Statement | [X] Medically Necessary | [ ] Investigational |
Population Reference No. 2
For individuals with signs and symptoms of breast disease, or a personal history of breast cancer, or a personal history of biopsy-proven benign breast disease. Intervention of interest is Diagnostic Mammography. Comparators of interest are other diagnostic and screening imaging available. Relevant outcomes include early detection and improvemnt of the net health outcome. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
| Population Reference No. 2 Policy Statement | [X] Medically Necessary | [ ] Investigational |
N/A
The USPSTF concludes with moderate certainty that the net benefit of screening mammography in women aged 50 to 74 years is moderate.
The USPSTF concludes with moderate certainty that the net benefit of screening mammography in the general population of women aged 40 to 49 years, while positive, is small.
The USPSTF concludes that the evidence on mammography screening in women age 75 years and older is insufficient, and the balance of benefits and harms cannot be determined.
The USPSTF concludes that the evidence on DBT as a primary screening modality for breast cancer is insufficient, and the balance of benefits and harms cannot be determined.
The USPSTF concludes that the evidence on adjunctive screening for breast cancer using breast ultrasound, MRI, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram is insufficient, and the balance of benefits and harms cannot be determined.
National Coverage Determination (NCD) for Mammograms (220.4)
Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L36342)
1. National Coverage Determination (NCD) for Mammograms (220.4)
2. Local Coverage Determination (LCD): Screening and Diagnostic Mammography (L36342)
3. USPSTF Final Recommendation Statement, Breast Cancer: Screening
| Codes | Number | Description |
| CPT | 77067 | Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed |
| | 77065 | Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral |
| | 77066 | Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral |
| ICD-10-CM | | Diagnosis codes for screening mammography |
| | Z12.31 | Encounter for screening mammogram for malignant neoplasm of breast |
| | | Diagnosis codes for diagnostic mammography |
| | C22.8 | Malignant neoplasm of liver, primary, unspecified as to type |
| | C43.52 | Malignant melanoma of skin of breast |
| | C43.59 | Malignant melanoma of other part of trunk |
| | C44.501 | Unspecified malignant neoplasm of skin of breast |
| | C44.509 | Unspecified malignant neoplasm of skin of other part of trunk |
| | C44.511 | Basal cell carcinoma of skin of breast |
| | C44.519 | Basal cell carcinoma of skin of other part of trunk |
| | C44.521 | Squamous cell carcinoma of skin of breast |
| | C44.529 | Squamous cell carcinoma of skin of other part of trunk |
| | C44.591 | Other specified malignant neoplasm of skin of breast |
| | C44.599 | Other specified malignant neoplasm of skin of other part of trunk |
| | C45.7 | Mesothelioma of other sites |
| | C45.9 | Mesothelioma, unspecified |
| | C4A.9 | Merkel cell carcinoma, unspecified |
| | C50.011 | Malignant neoplasm of nipple and areola, right female breast |
| | C50.012 | Malignant neoplasm of nipple and areola, left female breast |
| | C50.021 | Malignant neoplasm of nipple and areola, right male breast |
| | C50.022 | Malignant neoplasm of nipple and areola, left male breast |
| | C50.111 | Malignant neoplasm of central portion of right female breast |
| | C50.112 | Malignant neoplasm of central portion of left female breast |
| | C50.121 | Malignant neoplasm of central portion of right male breast |
| | C50.122 | Malignant neoplasm of central portion of left male breast |
| | C50.211 | Malignant neoplasm of upper-inner quadrant of right female breast |
| | C50.212 | Malignant neoplasm of upper-inner quadrant of left female breast |
| | C50.221 | Malignant neoplasm of upper-inner quadrant of right male breast |
| | C50.222 | Malignant neoplasm of upper-inner quadrant of left male breast |
| | C50.311 | Malignant neoplasm of lower-inner quadrant of right female breast |
| | C50.312 | Malignant neoplasm of lower-inner quadrant of left female breast |
| | C50.321 | Malignant neoplasm of lower-inner quadrant of right male breast |
| | C50.322 | Malignant neoplasm of lower-inner quadrant of left male breast |
| | C50.411 | Malignant neoplasm of upper-outer quadrant of right female breast |
| | C50.412 | Malignant neoplasm of upper-outer quadrant of left female breast |
| | C50.421 | Malignant neoplasm of upper-outer quadrant of right male breast |
| | C50.422 | Malignant neoplasm of upper-outer quadrant of left male breast |
| | C50.511 | Malignant neoplasm of lower-outer quadrant of right female breast |
| | C50.512 | Malignant neoplasm of lower-outer quadrant of left female breast |
| | C50.521 | Malignant neoplasm of lower-outer quadrant of right male breast |
| | C50.522 | Malignant neoplasm of lower-outer quadrant of left male breast |
| | C50.611 | Malignant neoplasm of axillary tail of right female breast |
| | C50.612 | Malignant neoplasm of axillary tail of left female breast |
| | C50.621 | Malignant neoplasm of axillary tail of right male breast |
| | C50.622 | Malignant neoplasm of axillary tail of left male breast |
| | C50.811 | Malignant neoplasm of overlapping sites of right female breast |
| | C50.812 | Malignant neoplasm of overlapping sites of left female breast |
| | C50.821 | Malignant neoplasm of overlapping sites of right male breast |
| | C50.822 | Malignant neoplasm of overlapping sites of left male breast |
| | C50.911 | Malignant neoplasm of unspecified site of right female breast |
| | C50.912 | Malignant neoplasm of unspecified site of left female breast |
| | C50.921 | Malignant neoplasm of unspecified site of right male breast |
| | C50.922 | Malignant neoplasm of unspecified site of left male breast |
| | C56.1 | Malignant neoplasm of right ovary |
| | C56.2 | Malignant neoplasm of left ovary |
| | C72.9 | Malignant neoplasm of central nervous sytem, unspecified |
| | C76.8 | Malignant neoplasm of other specified ill-defined sites |
| | C77.3 | Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes |
| | C78.01 | Secondary malignant neoplasm of right lung |
| | C78.02 | Secondary malignant neoplasm of left lung |
| | C78.1 | Secondary malignant neoplasm of mediastinum |
| | C78.2 | Secondary malignant neoplasm of pleura |
| | C78.7 | Secondary malignant neoplasm of liver and intrahepatic bile duct |
| | C79.2 | Secondary malignant neoplasm of skin |
| | C79.31 | Secondary malignant neoplasm of brain |
| | C79.32 | Secondary malignant neoplasm of cerebral meninges |
| | C79.40 | Secondary malignant neoplasm of unspecified part of nervous system |
| | C79.49 | Secondary malignant neoplasm of other parts of nervous system |
| | C79.51 | Secondary malignant neoplasm of bone |
| | C79.52 | Secondary malignant neoplasm of bone marrow |
| | C79.61 | Secondary malignant neoplasm of right ovary |
| | C79.62 | Secondary malignant neoplasm of left ovary |
| | C79.81 | Secondary malignant neoplasm of breast |
| | C80.0 | Disseminated malignant neoplasm, unspecified |
| | C80.1 | Malignant (primary) neoplasm, unspecified |
| | D03.52 | Melanoma in situ of breast (skin) (soft tissue) |
| | D03.59 | Melanoma in situ of other part of trunk |
| | D04.5 | Carcinoma in situ of skin of trunk |
| | D05.01 | Lobular carcinoma in situ of right breast |
| | D05.02 | Lobular carcinoma in situ of left breast |
| | D05.11 | Intraductal carcinoma in situ of right breast |
| | D05.12 | Intraductal carcinoma in situ of left breast |
| | D05.81 | Other specified type of carcinoma in situ of right breast |
| | D05.82 | Other specified type of carcinoma in situ of left breast |
| | D05.91 | Unspecified type of carcinoma in situ of right breast |
| | D05.92 | Unspecified type of carcinoma in situ of left breast |
| | D22.5 | Melanocytic nevi of trunk |
| | D23.5 | Other benign neoplasm of skin of trunk |
| | D24.1 | Benign neoplasm of right breast |
| | D24.2 | Benign neoplasm of left breast |
| | D48.5 | Neoplasm of uncertain behavior of skin |
| | D48.61 | Neoplasm of uncertain behavior of right breast |
| | D48.62 | Neoplasm of uncertain behavior of left breast |
| | D49.1 | Neoplasm of unspecified behavior of respiratory system |
| | D49.2 | Neoplasm of unspecified behavior of bone, soft tissue, and skin |
| | D49.3 | Neoplasm of unspecified behavior of breast |
| | D49.6 | Neoplasm of unspecified behavior of brain |
| | D49.7 | Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system |
| | I80.8 | Phlebitis and thrombophlebitis of other sites |
| | M70.80 | Other soft tissue disorders related to use, overuse and pressure of unspecified site |
| | M70.88 | Other soft tissue disorders related to use, overuse and pressure other site |
| | M70.89 | Other soft tissue disorders related to use, overuse and pressure multiple sites |
| | M70.90 | Unspecified soft tissue disorder related to use, overuse and pressure of unspecified site |
| | M70.98 | Unspecified soft tissue disorder related to use, overuse and pressure other |
| | M70.99 | Unspecified soft tissue disorder related to use, overuse and pressure multiple sites |
| | M79.5 | Residual foreign body in soft tissue |
| | M79.81 | Nontraumatic hematoma of soft tissue |
| | M79.89 | Other specified soft tissue disorders |
| | M79.9 | Soft tissue disorder, unspecified |
| | N60.01 | Solitary cyst of right breast |
| | N60.02 | Solitary cyst of left breast |
| | N60.11 | Diffuse cystic mastopathy of right breast |
| | N60.12 | Diffuse cystic mastopathy of left breast |
| | N60.21 | Fibroadenosis of right breast |
| | N60.22 | Fibroadenosis of left breast |
| | N60.31 | Fibrosclerosis of right breast |
| | N60.32 | Fibrosclerosis of left breast |
| | N60.41 | Mammary duct ectasia of right breast |
| | N60.42 | Mammary duct ectasia of left breast |
| | N60.81 | Other benign mammary dysplasias of right breast |
| | N60.82 | Other benign mammary dysplasias of left breast |
| | N60.91 | Unspecified benign mammary dysplasia of right breast |
| | N60.92 | Unspecified benign mammary dysplasia of left breast |
| | N61.0 | Mastitis without abscess |
| | N61.1 | Abscess of the breast and nipple |
| | N62 | Hypertrophy of breast |
| | N63.10 | Unspecified lump in the right breast, unspecified quadrant |
| | N63.11 - N63.14 | Unspecified lump in the right breast, upper outer quadrant - Unspecified lump in the right breast, lower inner quadrant |
| | N63.20 | Unspecified lump in the left breast, unspecified quadrant |
| | N63.21 - N63.24 | Unspecified lump in the left breast, upper outer quadrant - Unspecified lump in the left breast, lower inner quadrant |
| | N63.31 | Unspecified lump in axillary tail of the right breast |
| | N63.32 | Unspecified lump in axillary tail of the left breast |
| | N63.41 | Unspecified lump in right breast, subareolar |
| | N63.42 | Unspecified lump in left breast, subareolar |
| | N64.0 | Fissure and fistula of nipple |
| | N64.1 | Fat necrosis of breast |
| | N64.2 | Atrophy of breast |
| | N64.3 | Galactorrhea not associated with childbirth |
| | N64.4 | Mastodynia |
| | N64.51 | Induration of breast |
| | N64.52 | Nipple discharge |
| | N64.53 | Retraction of nipple |
| | N64.59 | Other signs and symptoms in breast |
| | N64.81 | Ptosis of breast |
| | N64.82 | Hypoplasia of breast |
| | N64.89 | Other specified disorders of breast |
| | N64.9 | Disorder of breast, unspecified |
| | N65.0 | Deformity of reconstructed breast |
| | N65.1 | Disproportion of reconstructed breast |
| | R59.0 | Localized enlarged lymph nodes |
| | R59.1 | Generalized enlarged lymph nodes |
| | R59.9 | Enlarged lymph nodes, unspecified |
| | R92.0 | Mammographic microcalcification found on diagnostic imaging of breast |
| | R92.1 | Mammographic calcification found on diagnostic imaging of breast |
| | R92.2 | Inconclusive mammogram |
| | R92.8 | Other abnormal and inconclusive findings on diagnostic imaging of breast |
| | R93.9 | Diagnostic imaging inconclusive due to excess body fat of patient |
| | S20.01XA | Contusion of right breast, initial encounter |
| | S20.02XA | Contusion of left breast, initial encounter |
| | S21.001A | Unspecified open wound of right breast, initial encounter |
| | S21.002A | Unspecified open wound of left breast, initial encounter |
| | S21.011A | Laceration without foreign body of right breast, initial encounter |
| | S21.012A | Laceration without foreign body of left breast, initial encounter |
| | S21.021A | Laceration with foreign body of right breast, initial encounter |
| | S21.022A | Laceration with foreign body of left breast, initial encounter |
| | S21.031A | Puncture wound without foreign body of right breast, initial encounter |
| | S21.032A | Puncture wound without foreign body of left breast, initial encounter |
| | S21.041A | Puncture wound with foreign body of right breast, initial encounter |
| | S21.042A | Puncture wound with foreign body of left breast, initial encounter |
| | S21.051A | Open bite of right breast, initial encounter |
| | S21.052A | Open bite of left breast, initial encounter |
| | S28.211A | Complete traumatic amputation of right breast, initial encounter |
| | S28.212A | Complete traumatic amputation of left breast, initial encounter |
| | S28.221A | Partial traumatic amputation of right breast, initial encounter |
| | S28.222A | Partial traumatic amputation of left breast, initial encounter |
| | S29.001A | Unspecified injury of muscle and tendon of front wall of thorax, initial encounter |
| | S29.009A | Unspecified injury of muscle and tendon of unspecified wall of thorax, initial encounter |
| | S29.091A | Other injury of muscle and tendon of front wall of thorax, initial encounter |
| | S29.099A | Other injury of muscle and tendon of unspecified wall of thorax, initial encounter |
| | S29.8XXA | Other specified injuries of thorax, initial encounter |
| | S29.9XXA | Unspecified injury of thorax, initial encounter |
| | S39.001A | Unspecified injury of muscle, fascia and tendon of abdomen, initial encounter |
| | S39.091A | Other injury of muscle, fascia and tendon of abdomen, initial encounter |
| | S39.81XA | Other specified injuries of abdomen, initial encounter |
| | S39.91XA | Unspecified injury of abdomen, initial encounter |
| | T85.41XA | Breakdown (mechanical) of breast prosthesis and implant, initial encounter |
| | T85.42XA | Displacement of breast prosthesis and implant, initial encounter |
| | T85.43XA | Leakage of breast prosthesis and implant, initial encounter |
| | T85.44XA | Capsular contracture of breast implant, initial encounter |
| | T85.49XA | Other mechanical complication of breast prosthesis and implant, initial encounter |
| | T85.79XA | Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter |
| | Z03.89 | Encounter for observation for other suspected diseases and conditions ruled out |
| | Z08 | Encounter for follow-up examination after completed treatment for malignant neoplasm |
| | Z77.123 | Contact with and (suspected) exposure to radon and other naturally occurring radiation |
| | Z77.128 | Contact with and (suspected) exposure to other hazards in the physical environment |
| | Z77.9 | Other contact with and (suspected) exposures hazardous to health |
| | Z85.3 | Personal history of malignant neoplasm of breast |
| | Z85.831 | Personal history of malignant neoplasm of soft tissue |
| | Z85.89 | Personal history of malignant neoplasm of other organs and systems |
| | Z86.000 | Personal history of in-situ neoplasm of breast |
| | Z91.89 | Other specified personal risk factors, not elsewhere classified |
| | Z92.89 | Personal history of other medical treatment |
| | Z98.82 | Breast implant status |
| | Z98.86 | Personal history of breast implant removal |
Some modifiers
| Date | Action | Description |
|---|---|---|
| 09/07/2023 | Policy Review | This policy will replace Policy 06.001.032 |
| 06/12/2019 | Revision | CPT and ICD-10 codes updated, policy format changed, policy guidilines updated. |
| 08/22/2017 | ||
| 05/10/2016 | ||
| 09/06/1013 | ICD-10 added | |
| 02/26/2013 | ||
| 02/24/2012 | ||
| 11/02/2011 | ICD-10 added | |
| 05/20/2009 | iCES | |
| 12/02/2007 | ||
| 03/01/2005 | ||
| 07/13/2000 |