ModifiedEmblemHealthPolicy AHS-G2059

Epithelial Cell Cytology in Breast Cancer Risk Assessment - Lab Benefit Program (LBM)

This reimbursement policy governs coverage and billing considerations for nipple aspiration, ductal lavage, and fine-needle aspiration cytologic analysis used to diagnose, screen for, or assess breast cancer risk under EmblemHealth's Lab Benefit Program (LBM). It affects providers submitting claims to EmblemHealth and members whose benefits determine coverage.

Policy Summary

PayerEmblemHealth

PolicyEpithelial Cell Cytology in Breast Cancer Risk Assessment - Lab Benefit Program (LBM)

Policy CodePolicy AHS-G2059

Change TypeCoverage criteria clarifiedcoding table updatesLBM expansion

Effective DateMar 1, 2023

Next Review Date

Key ActionDo not bill for cytologic analysis of epithelial cells (nipple aspiration, FNA) for diagnosis, screening, or breast cancer risk assessment as it does not meet coverage criteria.

SourceLink

POLICY UPDATE CHANGES

Coverage Criteria 1 clarified to state that cytologic analysis of epithelial cells to diagnose, screen for, or assess risk of developing breast cancer does not meet coverage criteria.

CPT codes 88172, 88173, and 88177 were added to the Applicable CPT/HCPCS Procedure Codes table.

Lab Benefit Program (LBM) expanded to include EmblemHealth HMO/PPO (Non-City) Commercial, Medicare and Medicaid plans effective 10/1/2024.

Policy text transferred to company-branded template; formatting/clarity updates at multiple dates with no coverage change.

Does not meet coverageNot covered

4CPT/HCPCS codes listed

>=17References

Policy Summary

PayerEmblemHealth

PolicyEpithelial Cell Cytology in Breast Cancer Risk Assessment - Lab Benefit Program (LBM)

Policy CodePolicy AHS-G2059

Change TypeCoverage criteria clarifiedcoding table updatesLBM expansion

Effective DateMar 1, 2023

Next Review Date

Key ActionDo not bill for cytologic analysis of epithelial cells (nipple aspiration, FNA) for diagnosis, screening, or breast cancer risk assessment as it does not meet coverage criteria.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Determinations

Coverage stance

Coverage determination based on available scientific evidence and individual benefit plans.

Cytologic analysis of epithelial cells (e.g., nipple aspiration, fine-needle aspiration [FNA]) to diagnose, to screen for, or to assess risk of developing breast cancer DOES NOT MEET COVERAGE CRITERIA.

Coverage Criteria

Coverage Criteria 1 (summary from revision history):

Cytologic analysis of epithelial cells (e.g., nipple aspiration, fine-needle aspiration [FNA]) to diagnose, to screen for, or to assess risk of developing breast cancer does not meet coverage criteria.

Applicable Procedure Codes

Applicable CPT codes referencedCPT

88108	Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno technique)
88112	Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
88172	Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site
88173	Cytopathology, evaluation of fine needle aspirate; interpretation and report
88177	Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure)

Applicable CPT/HCPCS Procedure CodesCPTNot Covered

88108	Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno technique)
88112	Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
88172	Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site
88173	Cytopathology, evaluation of fine needle aspirate; interpretation and report
88177	Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure)

Billing, Authorization, and Provider Responsibilities

Billing Rule

Billing and Coding Adherence

We follow coding edits based on industry sources including CPT guidelines (AMA), specialty organizations, and CMS (including NCCI and MUE). We apply the edits we determine appropriate when sources conflict and use industry-standard claims editing software for claim editing decisions. Upon request, we will provide an explanation of how we handle specific coding issues. If appropriate coding/billing guidelines or current reimbursement policies are not followed, the claim may be denied and/or payment recouped.

Follow AMA CPT® guidelines, specialty society guidance, and CMS (NCCI/MUE) edits.
We use industry-standard claims editing software to determine appropriate claim edits.
Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim denial and/or recoupment of payment.

Note

Government Supersession

If this policy conflicts with an applicable government policy for a specific member (for example, Medicare Local Coverage Determinations or National Coverage Determinations, or state Medicaid policies), the government policy supersedes and will be used to determine coverage. For the most up-to-date Medicare policies, visit the CMS Medicare Coverage Database; for Medicaid, refer to the applicable state Medicaid website.

Terms and Abbreviations

FNA

TermFNA

DefinitionFine-needle aspiration

ContextMethod to obtain epithelial cells for cytologic examination; less accurate than core biopsy for diagnosing breast malignancy (see policy coverage criteria)

NAF

TermNAF

DefinitionNipple aspirate fluid

ContextSpecimen type obtained for cytologic analysis in breast epithelial cell testing