Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
Annual Review
Prepared By
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options services for Mammography.
Definitions
Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.
Screening mammography – An x-ray of the breast used to aid in the detection of breast cancer in an individual with no signs or symptoms of disease.
Diagnostic mammography – An x-ray used to further evaluate a finding in a screening mammography or used when an individual has other signs or symptoms or a history of cancer.
Digital Breast Tomosynthesis (DBT) – A three-dimensional view of the breast using x-ray technology, where the x-ray tube moves in an arc around the stabilized breast, and these images (slices) are then sent to a computer to produce the three-dimensional image.
Policy Position
Prior Authorization
Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup
Prior authorization is not required.
Procedures
SCREENING MAMMOGRAPHY
Screening mammography including computer-aided detection (CAD) OR screening mammography with digital breast tomosynthesis are considered medically necessary once per calendar year for asymptomatic individuals with female anatomy forty years of age or older.
Self-referred screening mammograms for individuals with female anatomy under age forty (40) are not covered.
Prior to rendering the DBT service the following requirements for member safety, education and informed choice must be met:
- Provide educational materials to the patient outlining the study options so an informed decision can be made by the patient.
- Inform the patient of additional radiation exposure when both a 2-D mammography and 3-D DBT are performed.
Screening mammography not meeting the criteria as indicated in this policy is considered not medically necessary.
DIAGNOSTIC MAMMOGRAPHY
Diagnostic mammograms are covered according to a member’s individual or group customer benefits, that includes standard diagnostic mammography and diagnostic digital breast tomosynthesis.
Diagnostic mammography is completed when there are signs of a disease process such as:
- Breast symptoms (i.e. palpable breast lump, focal breast pain, suspicious nipple discharge)
- Callback from screening mammography
- Short term follows up for a finding seen on a prior diagnostic mammogram.
- Annual surveillance in patients with a history of breast cancer
Diagnostic mammography not meeting the criteria as indicated in this policy is considered not medically necessary.
POST-PAYMENT AUDIT STATEMENT
The medical record must include documentation that reflects the medical necessity criteria and is
subject to audit by Highmark Health Options at any time pursuant to the terms of your provider
agreement.
PLACE OF SERVICE: OUTPATIENT
Mammography is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
*Codes required to be reviewed by Evicore.
Modifiers
When only the professional component is performed, use modifier 26.
When only the technical component is performed, use modifier TC.
REIMBURSEMENT
Participating facilities will be reimbursed per their Highmark Health Options contract.
References
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer Screening and Diagnosis, Version 1.2021.
Hayes Inc. Medical Technology Directory. Digital Breast Tomosynthesis for Breast Cancer Diagnosis and Screening. Lansdale, PA: Hayes, Inc.; 06/29/2021.
Narayan A, Elkin E, Lehman C, Morris E. Quantifying performance thresholds for recommending screening mammography: a revealed preference analysis of USPSTF guidelines. Breast Cancer Research and Treatment. 2018;172:463–468.
He X, Schifferdecker K, Ozanne E, Tosteson A, Woloshin S and Schwartz L.How Do Women View Risk-Based Mammography Screening? A Qualitative Study. J Gen Intern Med. 2018;33(11):1905–12.
The American College of Obstetricians and Gynecologists. ACOG Practice Advisory on Breast Cancer Screening. Practice Bulletin Number 122. 2017. Reaffirmed 2019.
Helvie MA, Bevers TB. Screening mammography for average-risk women: The controversy and NCCN's position. J Natl Compr Canc Netw. 2018;16(11):1398-1404.
Chong A, Weinstein SP, McDonald ES, Conant EF. Digital breast tomosynthesis: Concepts and clinical practice. Radiology. 2019;292(1):1-14.
