CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mammography and Pap smear coverage (RI mandated)

Documents Rhode Island–mandated coverage guidelines for mammograms, Pap smears, and additional breast cancer screening (including for dense breasts) and who is affected (BCBSRI members; benefits may vary by plan).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMammography and Pap smear coverage (RI mandated)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2005

Next Review DateMar 7, 2024

Key ActionObtain prior authorization when ordering MRI or molecular breast imaging for dense-breast additional screening per §27-20-17(b)(2).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2paid screening mammograms per year for certain high-risk individuals

Annual/biennialrecommended mammography frequency (ACS)

25-65age range for primary HPV testing

MultipleProvider updates

State-Mandated Coverage & Screening Guidelines

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State-mandated coverage and screening guidelines (RI §27-20-17)

Covered when meeting the state‑mandated conditions and applicable guideline recommendations:

RI‑mandated baseline coverage: Subscribers shall be afforded coverage for mammograms and Pap smears in accordance with American Cancer Society guidelines.

Additional annual mammograms for high‑risk or recent breast cancer treatment: Two paid 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 or multiple first‑degree relatives) OR who have a high‑risk lesion on prior biopsy (lobular carcinoma in situ) OR atypical ductal hyperplasia.2 per year

Additional screening for dense breasts: Any screening deemed medically necessary for proper breast cancer screening in accordance with applicable American College of Radiology (ACR) guidelines, including but not limited to magnetic resonance imaging, ultrasound, and molecular breast imaging, for any person who has received notice of the existence of dense breast tissue under §23‑12.9‑2.per ACR guidance

Prior authorization may apply for some modalities.

Mammography frequency guidance (ACS): Women ages 40–44 may choose to begin annual screening; ages 45–54 should have annual mammograms; age 55 and older should switch to biennial screening or continue yearly screening. Continue screening while life expectancy is at least 10 years.age‑based

Cervical screening guidance (ACS): Begin cervical cancer screening at age 25. Ages 25–65: primary HPV testing every 5 years; if primary HPV testing unavailable, either co‑testing (HPV + Pap) every 5 years or Pap test alone every 3 years. Stop screening after age 65 if adequate prior screening and no history of CIN2+ in past 25 years. Special considerations apply for hysterectomy and HPV vaccination status.age‑based

Although Rhode Island–mandated benefits generally do not apply to Plan 65, FEHBP, and Medicare Advantage Plans, mammograms and Pap smears are covered for all BCBSRI members. Benefits may vary between groups; providers should refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine applicable diagnostic testing, imaging, laboratory, and screening coverage. Self-funded groups may opt out of state-mandated benefits.

Services that are determined to be not medically necessary or that qualify as non-covered benefits may be denied payment. Benefits and eligibility are governed by the member's subscriber agreement, member certificate, or employer agreement, which supersede this medical policy; for member-specific benefit information, contact the provider call center.

If services are determined to be not medically necessary, they may be considered non-covered and not payable. Providers may not bill the member for such services unless the member was informed and provided written agreement in advance to continue treatment at their own expense.

CPT / HCPCS Codes and Reimbursement Notes

Covered CPT Codes - Mammography (Medicare Advantage & Commercial)CPTCovered

77065	Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.
77066	Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.
77067	Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed.

Covered CPT / HCPCS Codes - Pap Smears / Cytopathology (Medicare Advantage & Commercial)mixedCovered

88141	Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician.
88142	Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision.
88143	Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening under physician supervision.
88147	Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision.
88148	Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision.
88150	Cytopathology, slides, cervical or vaginal; manual screening under physician supervision.
88152	Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision.
88153	Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision.
88164	Cytopathology, slides, cervical or vaginal (Bethesda System); manual screening under physician supervision.
88165	Cytopathology, slides, cervical or vaginal (Bethesda System); with manual screening and rescreening under physician supervision.

1–10 of 23

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Covered but not separately reimbursed (Medicare Advantage & Commercial)HCPCS/CPTCovered

G0101	Cervical or vaginal cancer screening; pelvic and clinical breast examination.
P3000	Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision.
P3001	Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician.
Q0091	Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory.

High-risk screening mammograms — inv-08

Coverage allowanceTwo paid screening mammograms per year when recommended by a physician for women treated for breast cancer within the last 5 years or who are at high risk (BRCA mutation, multiple first-degree relatives, high-risk lesion such as LCIS, or atypical ductal hyperplasia).

Triggering clinicianPhysician recommendation is required for the additional paid screening mammogram benefit.

Eligible populationWomen treated for breast cancer within the past 5 years or women identified as high risk for breast cancer due to genetic predisposition or specified high-risk pathology findings.

Statutory referenceRIGL §27-20-17(b)(1) mandates this coverage for subscribers to nonprofit medical service plans.

Prior Authorization, Billing, and Provider Notices

Prior Authorization

Prior authorization cross-reference

For coverage of magnetic resonance imaging and molecular breast imaging under R.I. Gen. Laws §27-20-17(b)(2), prior authorization may be required. See the related policy 'Prior Authorization of Cardiology and Radiology' for details on prior authorization submission requirements and processes.

Applies to MRI and molecular breast imaging when billed as additional screening for dense breasts
Follow the Prior Authorization of Cardiology and Radiology policy for submission portals, required clinical information, and turnaround times

Documentation Required

Benefits and eligibility verification

Benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement and may vary by group. Providers must verify member benefits, eligibility, and plan-specific coverage limits or exclusions prior to scheduling services.

Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for diagnostic testing, imaging, laboratory, and screening benefits
Contact the provider call center or use the payer’s online eligibility tools for member-specific benefit verification

Note

Provider notices — policy revision, billing, and member liability

This policy is current at the time of publication; however, medical practices, technology, and coverage rules may change. BCBSRI may review and revise this policy at any time and without notice. If services are determined to be not medically necessary or are non-covered benefits, providers may not bill the member unless the member has been informed and has provided written agreement to pay.

Providers should refer to their participation agreement(s) for billing and chargeback provisions
Do not charge members for services determined to be non-covered or not medically necessary unless documented written consent is obtained in advance

Key Terms

Mammography — inv-18

DefinitionImaging using low-dose X-rays to detect, characterize, and evaluate findings suggestive of breast cancer and other breast diseases; includes screening and diagnostic mammography.

Screening vs DiagnosticScreening mammography is for asymptomatic women; diagnostic mammography evaluates signs or symptoms of breast disease.

PurposeUsed for early detection and evaluation of breast abnormalities to guide further management.

Dense breast tissue — inv-19

DefinitionBreast tissue with higher fibroglandular density that appears white on mammograms, which can obscure detection of cancers and may increase cancer risk.

Impact on imagingDense tissue reduces mammogram sensitivity because both dense tissue and many lesions appear white, potentially prompting additional screening.

Clinical implicationPhysicians may recommend supplemental imaging for people notified of dense breasts to improve detection.

Pap smear / Cervical cancer screening — inv-20

DefinitionCollection and microscopic examination of cervical cells to detect cervical cancer or precancerous changes; may be performed as a Pap test alone, co-testing with HPV, or primary HPV testing per guidelines.

Screening initiationCervical cancer screening should begin at age 25 per American Cancer Society guidance.

Recommended modalities and intervalsAges 25–65: primary HPV testing every 5 years; if not available, co-test (HPV + Pap) every 5 years or Pap alone every 3 years.

DiscontinuationStop screening after age 65 if adequate prior screening and no history of CIN2+ in past 25 years; special rules apply after hysterectomy and for vaccinated individuals.

OpenPayer

Mammography and Pap smear coverage (RI mandated)

State-Mandated Coverage & Screening Guidelines

Additional Imaging & High-Risk Indications

CPT / HCPCS Codes and Reimbursement Notes

Screening Frequency and Limits

Prior Authorization, Billing, and Provider Notices

Prior Authorization Specifics

Key Terms

Clinical Background