CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Rhode Island Statutory Coverage for Mammograms and Pap Smears

Administrative policy documenting Rhode Island mandated coverage guidelines for mammography, Pap smear services, and additional breast cancer screening (including for dense breasts). Affects BCBSRI members and references benefit booklets and plan types.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyRhode Island Statutory Coverage for Mammograms and Pap Smears

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01|01 2024

Next Review DateN/A

Key ActionObtain prior authorization when requesting MRI or molecular breast imaging as additional screening for dense breasts or high-risk patients.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Twoscreening mammograms per year for certain high-risk women

40-44option to start annual mammography

45-54annual mammograms recommended

55+mammograms every 2 years or continue yearly

5cervical screening interval (yrs)

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Coverage criteria and policy notes

Coverage criteria and notes

Covered when the following statutory requirements and guidance are met; benefits may vary by group—refer to member Benefit Booklet/Evidence of Coverage or Subscriber Agreement.

ALL of the following

Subscribers shall be afforded coverage for mammograms and Pap smears in accordance with American Cancer Society guidelines.
RIGL 27-20-17 requires coverage per ACS guidelines.
Benefits may vary between groups; refer to the appropriate Benefit Booklet/Evidence of Coverage or Subscriber Agreement for applicable benefits.
Rhode Island-mandated benefits generally do not apply to Plan 65, FEHBP, and Medicare Advantage Plans, though mammograms and smears are covered for all BCBSRI members.

High‑risk or recent breast cancer: Two (2) screening mammograms per year when recommended by a physician for women who have been treated for breast cancer within the last five (5) years or who are at high risk of developing breast cancer due to genetic predisposition (BRCA gene mutation), multiple first‑degree relatives, or a high‑risk lesion on prior biopsy.

Additional screening for dense breasts: Additional screening services (MRI, molecular breast imaging, breast ultrasound) may be covered for members with dense breast tissue; prior authorization may apply for certain advanced imaging modalities.

See Prior Authorization of Cardiology and Radiology policy for MRI and molecular breast imaging authorization requirements.

Cervical cancer screening schedule

Begin cervical cancer screening at age 25.
Primary HPV test every 5 years for ages 25–65, or if primary HPV testing is not available, either: (a) co‑test (HPV + Pap) every 5 years; or (b) Pap test alone every 3 years.
Stop screening after age 65 if prior screening has been adequate and there is no history that would indicate continued screening.

Coding and claims note: Medicare Advantage plans may list G‑codes; commercial claims should use appropriate CPT codes. Refer to coding tables for covered mammography, cytology, MRI, molecular breast imaging, and ultrasound codes.

Covered codes and coding notes

Covered mammography and cytology codes (Medicare Advantage and Commercial)mixedCovered

77065	Diagnostic mammography, unilateral
77066	Diagnostic mammography, bilateral
77067	Screening mammography, bilateral
88141	Cytopathology, cervical or vaginal; requiring physician interpretation
G0123	Screening cytopathology, collected in preservative fluid; screening by cytotechnologist
77046	MRI breast without contrast, unilateral
77048	MRI breast without and with contrast; unilateral
78800	Molecular breast imaging (radiopharmaceutical localization), planar
76641	Breast ultrasound, unilateral, complete

Related coding/resource policymixed

No codes listed

Cervical screening start age

Cervical screening start ageBegin cervical cancer screening at age 25 (primary HPV testing every 5 years or alternatives as noted).

Screening modalityPrimary HPV test every 5 years for ages 25–65; if not available, co-test (HPV + Pap) every 5 years or Pap alone every 3 years.

Age range referencedApplies to persons aged 25 through 65.

Cervical screening stop criteria

Stop criteriaStop cervical cancer screening after age 65 provided there has been adequate prior screening and no history placing the person at high risk.

Adequate prior screening

Provider actions, authorizations, and eligibility

Prior Authorization

Prior Authorization Required

Prior authorization may be required for advanced breast imaging (e.g., breast MRI and molecular breast imaging). For details on prior authorization requirements and submission instructions, see the payer's Prior Authorization of Cardiology and Radiology policy referenced under §27-20-17(6)(2).

Affected procedures include breast MRI (CPT 77046–77049) and molecular breast imaging (nuclear medicine codes such as 78800, 78801)

Note

Verify Member Eligibility and Benefits

Benefits and eligibility (including whether prior authorization is required for a specific member) are determined by the member's subscriber agreement or employer contract. Providers must contact the BCBSRI provider call center to verify member-specific benefits and eligibility before providing services.

Do not rely solely on this medical policy to determine coverage or member liability.
If services are not covered or are determined not medically necessary, the provider may not bill the member unless the member was informed and provided written agreement to pay.

Definitions and statutory references

Mammography definition

DefinitionMammography: imaging that uses low-dose X-rays to examine the breasts for detection, characterization, and evaluation of findings suggestive of breast cancer and other breast diseases.

Screening mammographyUsed for early detection of breast cancer in asymptomatic women.

Diagnostic mammographyUsed to evaluate signs or symptoms of breast disease (to diagnose suspected breast cancer).

Dense breast tissue

DefinitionDense breast tissue: breast tissue that appears white on a mammogram and can obscure both benign and malignant lumps, making detection more difficult.

Clinical implicationDense breasts may increase the risk of developing breast cancer and reduce mammogram sensitivity (lower accuracy).