CurrentAlliance HealthPolicy 1K-1

Breast Imaging Procedures

Defines coverage, medical necessity criteria, prior approval and billing information for breast imaging services (mammography, ultrasound, MRI, ductogram, image-guided biopsy) for NC Medicaid beneficiaries and providers.

Policy Summary

PayerAlliance Health

PolicyBreast Imaging Procedures

Policy CodePolicy 1K-1

Change TypeMinor / no material change

Effective Date

Next Review Date

Key ActionVerify beneficiary eligibility and obtain required prior approval for listed breast MRI and select ultrasound CPT codes when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5modalities

1/yrannual screening ≥40

1/5yrbaseline 35–39

males not coveredsex-specific exclusion

appliesEPSDT

Coverage and Medical Necessity Criteria

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inv-01: General Criteria Covered

Covered when ALL of the following are met:

General medical necessity: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

From general criteria covered.

inv-03: General Criteria Covered

Covered when ALL of the following general criteria are met

General coverage criteria: a. Individualized, specific, consistent with symptoms/diagnosis and not in excess of beneficiary's needs; b. Safely furnished and no equally effective, more conservative or less costly treatment available statewide; c. Not primarily for convenience of beneficiary, caretaker, or provider.

From general criteria covered.

inv-02: Diagnostic Mammography — Covered Indications

Diagnostic mammography is medically necessary when ANY of the following apply:

Diagnostic mammography indications: A. personal history of malignant neoplasm of the breast; OR B. diagnosed with benign mammary dysplasia(s); OR C. diagnosed with other disorders of the breast.

Applies to male and female beneficiaries of all ages.

inv-04: Diagnostic Mammography

Diagnostic mammography is covered when ANY of the following apply

Diagnostic mammography indications: A. Personal history of malignant neoplasm of the breast; B. Diagnosed benign mammary dysplasia(s); C. Diagnosed other disorders of the breast.

Applies to male and female beneficiaries of all ages.

inv-05: Computer Aided Detection

Computer-aided detection

CAD use: Computer-aided detection (CAD) may be used to improve radiologists' ability to identify suspicious areas on screening or diagnostic mammograms; the radiologist remains the official reader and interpreter.

CAD is an add-on process for film or digital mammography.

inv-06: Breast Ultrasound

Breast ultrasound is covered when ANY of the following apply

Breast ultrasound indications: 1. To evaluate problems found during a screening or diagnostic mammogram; 2. For use during a biopsy procedure for breast lesions; 3. To evaluate a clinical abnormality.

Breast ultrasound uses a handheld instrument to transmit high-frequency sound waves through the breast.

inv-07: Breast MRI

Breast MRI is covered for the following indications

High genetic risk: 1. Known BRCA1/2 mutation in beneficiary; 2. Known BRCA1/2 mutation in relatives; 3. pattern of breast cancer in multiple first-degree relatives (often young and bilateral).

MRI used for detection in beneficiaries at high genetic risk.

Other MRI indications: 2. Beneficiaries with breast characteristics limiting mammography sensitivity (dense breasts, implants, scarring); 3. Suspected occult primary with axillary nodal adenocarcinoma and negative mammography/clinical exam; 4. New diagnosis of breast cancer to determine extent and/or evaluate contralateral breast; 5. Evaluate implant integrity.

MRI produces detailed cross-sectional images to show breast tissue details.

inv-08: Ductogram (Galactogram)

Ductogram coverage

Ductogram indication: Ductogram (galactogram) is covered for the diagnosis of the cause of abnormal nipple discharge.

Contrast medium may be used intraductally to outline the duct when evaluating nipple discharge.

inv-09: Image-Guided Breast Biopsy

Image-guided biopsy coverage

Image-guided breast biopsy indication: Covered when radiological supervision and interpretation is required for needle placement and/or for biopsy to obtain tissue for pathological examination.

Imaging tests may be done to ensure correct sampling of the suspicious area.

inv-10: Screening Mammography

Screening mammography coverage by age

Women 20-39 with high-risk: For female beneficiaries ages 20 through 39: one exam annually when the beneficiary has a documented positive BRCA mutation, personal history of ovarian cancer, personal history of chest radiation, personal history of atypical/high-risk biopsy(ies), or strong family history (first-degree relative).one per year for qualifying high-risk

See Attachment A for specific diagnosis codes.

Women 35-39 baseline: For female beneficiaries ages 35 through 39: one baseline exam within five years.one in five years

Baseline screening once in five years.

Women >=40: For female beneficiaries ages 40 years and older: one exam annually.one per year

inv-11: Screening and Diagnostic Mammography Coverage

Coverage rules by age group and indication as presented in the ICD-10 coding table

Screening mammography ages 40+: Annual screening mammography is allowed for beneficiaries ages 40 years and older; primary diagnosis codes Z12.39 or Z12.31 may be used.

Referenced in coding table (Attachment A).

Screening mammography ages 35-39: Screening mammography ages 35 through 39 is allowed as a baseline once in five years; primary diagnosis codes Z12.39 or Z12.31 may be used.Baseline once in five years

Referenced in coding table.

Screening mammography ages 20-39 (annual for high risk): Annual screening mammography ages 20 through 39 is allowed when a required secondary diagnosis indicating high risk is present (see coding table for required secondary codes such as Z85.3 and related codes).Secondary diagnosis required

inv-12: Allowed Diagnoses

Allowed diagnoses for diagnostic or screening mammography and related procedures as listed

Allowed ICD-10 primary or secondary diagnoses: Use the enumerated ICD-10-CM codes as primary or secondary diagnoses to support medical necessity for diagnostic and screening mammography and related breast imaging services (includes numerous C50.x, N60/N63/N64, R92.x, Z12.x, Z85.3 and related codes).

See chunks 54-58 (Attachment A) for the full code list.

inv-13: Billing Units Limit

Billing limitations

Billing units per date of service: Coverage is limited to one procedure per date of service by the same or different provider unless an appropriate modifier is appended to the procedure code.

Providers should append appropriate modifiers when multiple procedures on same date of service are clinically indicated.

For beneficiaries under 21 years of age, the EPSDT special provision allows coverage of otherwise limited services when the provider documents that the requested service is medically necessary to correct or ameliorate a condition identified through screening. However, EPSDT does not require coverage of services that are unsafe, ineffective, or experimental/investigational; those services remain excluded even for beneficiaries under 21. Providers must document how the service meets EPSDT requirements and note that prior approval requirements remain applicable when specified elsewhere in policy.

Screening mammography is explicitly excluded for male beneficiaries. Ordering or billing screening mammography for males will not meet coverage criteria and should not be submitted for reimbursement under this policy.

Services are not covered when any of the following apply: the beneficiary does not meet enrollment or eligibility requirements, the beneficiary does not meet the policy's medical necessity criteria, the service duplicates another provider's procedure, or the service is experimental/investigational or part of a clinical trial. Claims that meet any of these conditions may be denied.

Not covered: Screening mammography for male beneficiaries. This exclusion applies regardless of age and must be followed when determining coverage and submitting claims.

Appropriate Indications by Modality

inv-51: Appropriate indications per modality as defined in sections 1.1.1–1.1.5

Appropriate indications per modality as defined in sections 1.1.1–1.1.5

Modality indications summary: Mammography: screening for asymptomatic women and diagnostic for symptomatic persons or those with personal history; Ultrasound: to evaluate problems found during mammography or on exam and to guide biopsy; MRI: detailed cross-sectional imaging for high-risk patients, limited mammography sensitivity, staging or extent of disease, occult primary, or implant evaluation; Ductogram: evaluate abnormal nipple discharge; Image-guided biopsy: when radiologic supervision/interpretation is required for needle placement/biopsy.

Consolidated from sections 1.1.1–1.1.5.

inv-52: Breast imaging indications by modality

Breast imaging indications by modality

Diagnostic mammography indications: Personal history of malignant neoplasm of the breast; benign mammary dysplasia; other disorders of the breast.

Diagnostic mammography applies to male and female beneficiaries of all ages.

Ultrasound indications: Evaluate problems found during a screening or diagnostic mammogram; use during biopsy procedures for breast lesions; evaluate a clinical abnormality.

MRI indications: High genetic risk (BRCA mutation in beneficiary or relatives, strong family pattern), limited mammography sensitivity (dense breasts, implants, scarring), suspected occult primary with axillary nodal adenocarcinoma and negative mammography/clinical exam, new diagnosis to determine extent/contralateral disease, evaluate implant integrity.

Ductogram indication: Diagnosis of the cause of abnormal nipple discharge.

Image-guided biopsy indication: When radiological supervision and interpretation is required for needle placement and/or for biopsy to obtain tissue for pathology.

inv-53: Screening mammography by age and risk

Screening mammography by age and risk

Ages 40 and older: Annual screening mammography is allowed for beneficiaries ages 40 years and older using primary diagnosis Z12.39 or Z12.31.one per year

See Attachment A for code usage.

Ages 35–39 baseline: For ages 35–39, one baseline screening mammogram within five years is allowed (primary diagnosis Z12.39 or Z12.31).one in five years

Ages 20–39 high risk: Ages 20–39: annual screening allowed only when a required secondary high-risk diagnosis code is present (see coding table for specific secondary codes such as Z85.3 and related codes).secondary diagnosis required

inv-54: Diagnostic mammography indications (list of allowed ICD-10-CM codes)

Diagnostic mammography indications (list of allowed ICD-10-CM codes)

Allowed diagnostic ICD-10 codes: Diagnostic mammography is indicated for signs, symptoms, or history supported by the enumerated ICD-10-CM codes (examples include extensive C50.x series, N60/N63/N64 series, and R92.x codes).

Full code list provided in Attachment A (chunks 50–55).

inv-55: Diagnostic or screening mammography based on listed ICD-10-CM codes

Diagnostic or screening mammography based on listed ICD-10-CM codes

Indication by ICD-10: Diagnostic or screening mammography and related breast imaging services are covered when supported by the enumerated ICD-10-CM primary or secondary diagnosis codes listed in Attachment A (includes Z12.x, Z85.3, numerous C50.x, N60–N64, and R92.x codes).

See chunks 54–58 for full enumerated list.

Codes and Diagnosis Lists

Covered CPT/HCPCS CodesCPTCovered

77063	Screening digital breast tomosynthesis; unilateral or bilateral
77065	Diagnostic mammography; unilateral
77066	Diagnostic mammography; bilateral
77067	Screening mammography, bilateral; includes digital breast tomosynthesis when performed
G0279	Diagnostic mammography, computer-aided detection, unilateral or bilateral
77053	Ductogram, including injection for ductography
77054	Ductogram, bilateral
77046	Magnetic resonance imaging, breast, without contrast material, followed by contrast and further sequences
77047	Magnetic resonance imaging, breast, without contrast material, followed by contrast and further sequences; bilateral
77048	Magnetic resonance imaging, breast, without contrast material, followed by contrast and further sequences; unilateral

1–10 of 15

1/2

Mammography and related CPT/HCPCS codes (added/updated)CPTCovered

77065	Mammography, screening (digital) w/ tomosynthesis
77066	Diagnostic mammography (digital) w/ tomosynthesis
77067	Bilateral diagnostic mammography w/ tomosynthesis
G0279	Bilateral screening mammography (digital) conversion code (as listed)
77063	Breast MRI (added 06/01/2018 as noted)

ICD-10-CM codes allowed for screening and diagnostic mammography (examples from list)ICD-10

Z12.39	Encounter for screening mammogram for malignant neoplasm of breast (general screening code shown as allowed for annual screening ages 40+ and for other screening categories)
Z12.31	Encounter for screening mammogram for malignant neoplasm of breast (alternate screening code shown)
Z85.3	Personal history of malignant neoplasm of breast (used as secondary/primary allowed for diagnostic mammography)
C50.612	Malignant neoplasm of unspecified site of left female breast (example diagnostic code)
N61.0	Chronic mastitis (example diagnostic code added)

Allowed ICD-10-CM Codes (examples from list)ICD-10

R92.0	Abnormal mammogram
R92.1	Other abnormal and inconclusive findings on diagnostic imaging of breast
R92.2	Inconclusive mammogram
Z12.31	Encounter for screening mammogram for malignant neoplasm of breast
Z12.39	Encounter for other screening for malignant neoplasm of breast
Z85.3	Personal history of malignant neoplasm of breast
Z77.110	Contact with and (suspected) exposure to environmental pollution

Screening mammography diagnoses by age (referenced Attachment A for specific codes)mixed

Z12.39	Primary diagnosis allowed for annual screening mammography for ages 40 years and older (Attachment A)
Z12.31	Primary diagnosis allowed for screening mammography (used for ages 20-39 with restrictions and other age bands as specified in Attachment A)

Interval between annual mammograms

Minimum intervalAt least 11 complete calendar months must elapse between annual mammograms for the Medicaid service to be covered.

Applies toScreening mammograms for female Medicaid beneficiaries per annual frequency rules.

Related limitation noteThe 11-month rule ensures annual screening claims are not billed more frequently than allowed.

All listed breast imaging modalities — One procedure per date of service

Per-date-of-service limitCoverage is limited to one procedure per date of service by the same or different provider unless an appropriate modifier is appended to the procedure code.

Applies toAll listed breast imaging modalities (mammography, ultrasound, MRI, ductogram, image-guided biopsy).

Modifier exceptionAn appropriate modifier may be appended to allow additional procedures on the same date of service when supported by documentation and coding guidelines.

Screening Frequency and Limits

Mammography frequency

Routine screening (ages ≥40)One screening mammogram per year for female beneficiaries ages 40 and older.

High-risk females 20–39One screening mammogram per year for female beneficiaries ages 20–39 when a qualifying high-risk diagnosis is documented.

Baseline for ages 35–39One baseline screening mammogram within a five‑year period for female beneficiaries ages 35 through 39 to establish a baseline.

Mammography (screening) — Baseline once in five years

Baseline frequencyFor female beneficiaries ages 35 through 39: baseline screening mammogram once in five years.

Allowed primary diagnosis codesPrimary diagnosis codes Z12.39 or Z12.31 may be used for screening mammography claims per the coding table.

ScopeBaseline provision applies to Medicaid beneficiaries as described in the attachment/code table.

Mammography (screening) — Annual

Annual screeningOne screening mammogram per year for female beneficiaries ages 40 and older.

High-risk ages 20–39Annual screening allowed for female beneficiaries ages 20–39 when a qualifying high‑risk secondary diagnosis is present.

Interval requirementAt least 11 complete calendar months must elapse between annual mammograms for coverage.

All listed breast imaging modalities — One procedure per date of service

Single procedure ruleCoverage is limited to one procedure per date of service by the same or different provider unless an appropriate modifier is appended.

Modalities coveredApplies across all listed breast imaging modalities (mammography, ultrasound, MRI, ductogram, image-guided biopsy).

Documentation requirementWhen multiple procedures are billed on the same date, documentation and correct modifier use must support medical necessity per coding guidelines.

Provider Responsibilities and Billing Requirements

Denial Risk

Eligibility verification

An eligible beneficiary must be enrolled in the NC Medicaid Program. Providers must verify each beneficiary's Medicaid eligibility at the time of service; services may be denied if the beneficiary is not enrolled or eligibility is not verified. Beneficiaries may have service restrictions based on eligibility category that could make them ineligible for a particular service.

Verify beneficiary enrollment in NC Medicaid at each visit.
Confirm any service restrictions tied to the beneficiary's eligibility category.

Billing Rule

Provider enrollment and billing eligibility

Providers must meet Medicaid participation qualifications, maintain a current signed DHHS Provider Administrative Participation Agreement, and bill only for services within the scope of their clinical practice as defined by the appropriate licensing entity. Failure to meet enrollment or billing eligibility requirements may result in claim denial.

Be currently enrolled and in good standing with Medicaid.
Maintain a signed DHHS Provider Administrative Participation Agreement.
Bill only for services within your licensed scope of practice.

Billing Rule

Billing compliance

Claims must be submitted according to the National Uniform Billing Guidelines (UB-04/837I for institutional) and National Coding Guidelines (CMS-1500/837P for professional). Noncompliant billing or claim submission may result in denial.

Use CMS-1500/837P for professional claims and UB-04/837I for institutional claims.
Institutional claims must follow National Uniform Billing Guidelines.
All claims must comply with National Coding Guidelines.

Documentation Required

Coding specificity (ICD-10)

Report ICD-10-CM and PCS diagnosis and procedure codes to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at the time of service.

Use the current ICD-10-CM/PCS edition and report codes to the highest level of specificity that supports medical necessity.

Documentation Required

Coding specificity and unlisted procedure documentation

Report the most specific CPT/HCPCS/revenue code that accurately and completely describes the service. If no specific code exists, use the appropriate unlisted procedure/service code and provide the required documentation or special report per CPT and HCPCS instructions.

Use current CPT, HCPCS, and UB-04 Data Specifications Manual editions in effect at time of service.
When no specific code exists, bill an appropriate unlisted code and include the CPT/HCPCS required special report/documentation.
Follow the CPT and HCPCS Instructions for Use for unlisted procedures and special reports.

Prior Authorization

Prior approval required for specific MRI/ultrasound codes

Certain MRI and ultrasound CPT codes require prior approval for Medicaid beneficiaries. Failure to obtain required prior approval may result in denial of the service.

MRI codes requiring prior approval: 77046, 77047, 77048, 77049, 76377, 77021.
Ultrasound codes requiring prior approval: 76641, 76642.
EPSDT does not waive prior approval requirements for beneficiaries under 21; if prior approval is required by this policy it must still be obtained.

Contrast Use and Special Procedure Notes

Billing Rule

Use intraductal contrast for ductogram (galactogram)

Ductogram (galactogram) uses a thin catheter placed into the nipple duct and injection of a small amount of contrast medium intraductally to outline the duct on X‑ray when evaluating nipple discharge.

Prior Authorization

Breast MRI codes require prior approval for Medicaid beneficiaries

Breast MRI and related MRI codes listed in the policy (e.g., 77046–77049, 76377, 77021) require prior approval for Medicaid beneficiaries per the policy's code list and notes.

Billing Rule

Follow full policy and CPT/HCPCS guidance for contrast use

Refer to the full policy for additional procedural contrast safety and usage instructions; follow CPT/HCPCS guidance and the policy's contrast rules when administering contrast.

Background and Purpose

Breast imaging is used to detect and evaluate breast abnormalities, including breast cancer. Covered modalities include screening and diagnostic mammography, breast ultrasound, breast MRI, ductogram (galactogram), and image-guided breast biopsy, each applied according to the indications and coverage criteria in this policy.

Key Definitions

Screening mammogram definition

DefinitionScreening mammogram: a radiologic procedure (film or digital) furnished to a woman without signs or symptoms of breast disease for early detection of breast cancer.

Typical usePerformed as a preventive health service to detect asymptomatic breast cancer in eligible female beneficiaries.

Coding guidanceUse primary screening ICD-10-CM codes (e.g., Z12.39 or Z12.31) as indicated in the coding table for screening claims.

Diagnostic mammogram definition

DefinitionDiagnostic mammogram: a radiologic procedure (film or digital) furnished to a man or woman with signs or symptoms of breast disease, a personal history of breast cancer, or a personal history of biopsy‑proven benign breast disease.

IndicationsUsed to evaluate symptomatic patients, follow up abnormal screening findings, or assess known breast disease or prior biopsies.

CodingDiagnostic mammography may be billed with primary or secondary diagnostic ICD‑10‑CM codes enumerated in the policy (see Attachment A).

Breast tomosynthesis definition

DefinitionBreast tomosynthesis (3D mammography): an advanced form of breast imaging that uses computer reconstruction to create a three‑dimensional image of the breast (also called digital breast tomosynthesis).

Relation to mammographyTomosynthesis may be performed in conjunction with screening or diagnostic mammography; policy recognizes tomosynthesis as a defined mammography technique.

Revision noteDefinition for breast tomosynthesis was added in the policy revision dated 05/01/2018.

CAD definition

DefinitionComputer-aided detection (CAD) is software that assists radiologists by identifying areas on screening or diagnostic mammograms that may warrant further review; the radiologist remains the official reader.

RoleCAD improves ability to identify potentially suspicious areas but does not replace the radiologist's interpretation.

UsesApplies to both film (scanned/digitized) and digital mammography as an add‑on processing step.

Breast tomosynthesis (alternate) definition

Alternate wordingBreast tomosynthesis, also known as 3D mammography or digital breast tomosynthesis, is an advanced form of breast imaging that uses computer reconstruction to create a three‑dimensional image of the breast.

Synonyms3D mammography; digital breast tomosynthesis.

Policy historyTomosynthesis definition explicitly added in the May 1, 2018 policy revision.

Allowed ICD-10-CM diagnoses (definition/list reference)

Definition/list referenceAllowed ICD‑10‑CM diagnoses: the policy enumerates specific ICD‑10‑CM codes that may be used as primary or secondary diagnoses to support screening or diagnostic mammography (examples include Z12.31, Z12.39, Z85.3, R92.0 and multiple C50.x and N60/N63 series codes).

Use for screening ages 40+Primary diagnosis codes Z12.39 or Z12.31 are listed as allowed for annual screening mammography ages 40 and older.

High‑risk screening ages 20–39Annual screening for ages 20–39 requires a qualifying secondary high‑risk diagnosis code as listed in the policy (see Attachment A).

Prior Authorization Rules

Prior Authorization

Prior approval still required when specified elsewhere

Prior approval remains required for any modality when prior approval is specifically specified elsewhere in this policy or its attachments; EPSDT does not remove that requirement.

Note

Routine modalities generally do not require prior approval

The policy states that none of the listed modalities require prior approval under the general Prior Approval section ('None Apply'), meaning routine modalities in this policy do not require prior approval unless otherwise specified.

Prior Authorization

Specific MRI and ultrasound codes require prior approval

Prior approval is required for the listed breast MRI CPT codes (77046–77049, 76377, 77021) and ultrasound codes 76641 and 76642 for Medicaid beneficiaries; these specific codes are noted in the code section as requiring prior approval.

Exclusions and Not Covered Services

Screening mammography for male beneficiaries is not covered under this policy and should not be billed as a covered preventive screening for male Medicaid enrollees.

Non-coverage conditions include situations where the beneficiary fails to meet enrollment or eligibility requirements, the requested service does not meet the policy's medical necessity criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial. Providers should verify eligibility and confirm that services meet the stated criteria before submission to avoid denials.

Policy Revision History

2023-10-15ICD-10 updateLatest

Attachment A revised and ICD-10 code updates made effective 2023-10-01.

2023-06-01Template update & posting

Policy template language updated due to North Carolina Health Choice Program's move to Medicaid; policy posted with effective date 2023-04-01.

2023-03-01Prior authorization removed

Prior authorization requirement and reference to Policy 1K-7 for imaging were removed; Place of Service updated to include Independent Diagnostic Testing Facility.

Policy Summary

PayerAlliance Health

PolicyBreast Imaging Procedures

Policy CodePolicy 1K-1

Change TypeMinor / no material change

Effective Date

Next Review Date

Key ActionVerify beneficiary eligibility and obtain required prior approval for listed breast MRI and select ultrasound CPT codes when applicable.

SourceLink

On This Page

At least 11 complete calendar months must elapse between annual mammograms for coverage.

See Attachment A for specific secondary diagnosis codes.

Diagnostic mammography is allowed with primary or secondary diagnostic ICD-10-CM codes indicating suspicious findings or breast disease (extensive list of C50.x, N6x, R92.x codes provided).

See Attachment A for full enumerated list.