CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Screening and diagnostic mammography coverage

Defines coverage, reimbursement, coding, and documentation requirements for screening and diagnostic mammography for Neighborhood Health Plan of Rhode Island members across Medicaid, Integrity, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyScreening and diagnostic mammography coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionVerify eligibility, coverage and prior authorization requirements with Neighborhood before providing mammography services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Annualages 45-54 interval

40-44option start age

Biennial/Annual55+ interval

2/yrhigh-risk coverage

Listedcodes provided

Coverage Criteria for Screening and Diagnostic Mammography

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Screening and high-risk screening criteria

Covered when the following age- and risk-based criteria are met:

Average risk screening by age: Women 40-44: option to begin annual screening; Women 45-54: annual screening; Women 55+: switch to every other year or continue yearly; continue screening if in good health and expected to live >=10 yearsage-based

Applies to women at average risk as defined in reimbursement requirements

High risk or recent treatment: Two screening mammograms per year are covered when recommended by a physician for women treated for breast cancer within the last five years or at high risk due to genetic predisposition (BRCA gene mutation or multiple first-degree relatives), high-risk lesion on prior biopsy (lobular carcinoma in situ), or atypical ductal hyperplasia2 per year

Physician recommendation required

Women are categorized as average risk for screening if they do not have a personal history of breast cancer, do not have a strong family history of breast cancer, do not carry a known high-risk genetic mutation (for example, a BRCA gene mutation), and have not received chest radiation therapy before age 30. Women who meet these average-risk criteria follow the age-based screening intervals outlined below; women who do not meet these criteria are managed under the high-risk guidance.

See the primary policy text for the full set of coverage criteria and exceptions, including age-based screening intervals and the separate guidance that applies to high-risk patients and those with recent breast cancer treatment.

Coding and Frequency Limits

Covered CPT/HCPCS CodesCPTCovered

77063	Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).
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.

inv-05: Screening frequency

Recommended screening (ages 45-54)Annual mammography

Optional start (ages 40-44)Option to begin annual screening

Screening (55 and older)Switch to biennial or continue annual; continue while in good health and life expectancy ≥10 years

High-risk or recent treatmentTwo screening mammograms per year when recommended by a physician for women treated for breast cancer within last 5 years or at high risk

inv-15: Mammography frequency limits

Standard annual limitOne screening mammogram per recommended interval by age (see screening frequency)

Exception - high risk or recent treatmentTwo screening mammograms per year covered when physician recommends for women treated for breast cancer within last 5 years or at high risk

Documentation requirementPhysician recommendation required to justify second screening within 12 months

Provider Actions, Documentation, and Billing Requirements

Prior Authorization

Verify Prior Authorization and Eligibility

Providers must verify eligibility, coverage, and prior authorization requirements before providing services. Refer to Neighborhood's plan-specific resources (Prior Authorization Reference page and Clinical Medical Policies) and contact Provider Services at 1-800-963-1001 with questions.

Verify member eligibility and benefits prior to service
Check plan-specific prior authorization requirements and obtain authorization when required
Contact Provider Services: 1-800-963-1001

Documentation Required

Medical Record Support and Documentation

Providers must maintain complete medical records that support the services billed and the medical necessity of those services. Neighborhood may request supporting records and follows CMS standards for documentation.

Document reason for service, relevant history, exam findings, diagnostic test results, treatments provided, and clinical rationale
Retain records for the period required by contract and state law
Provide records promptly when requested for review or audit

Billing Rule

Claim Submission and Timeliness

Claims must be submitted in accordance with contractual timely filing guidelines and coding standards. Claims may be denied if billing, coding, or timely filing requirements in provider contracts are not met.

Submit complete and accurate claims within the contractually specified timely filing window
Use correct CPT, ICD-10-CM, and HCPCS codes and modifiers per AMA and CMS guidance
Claims with missing documentation or incorrect coding are subject to denial or repayment

Denial Risk

Documentation Risk and Denial Conditions

Services lacking documentation that supports the billed services and medical necessity are subject to audit and potential denial. Neighborhood may request records and will apply medical necessity criteria (NCD, LCD, InterQual, RI EOHHS, Clinical Medical Policies) when reviewing services.

Failure to provide adequate documentation when requested may result in denial or recoupment
Maintain documentation consistent with CMS standards to reduce audit risk

Prior Authorization Requirements

Prior Authorization

Mammography prior authorization

Providers must verify plan-specific prior authorization requirements for mammography via Neighborhood's Prior Authorization Reference; some plans may require prior authorization before services are rendered.

Check the Prior Authorization Reference to determine if a prior authorization is required for the member's plan and the specific mammography CPT/HCPCS code.
Confirm authorization status before scheduling or performing the exam.

Key Definitions

inv-12: Screening

DefinitionTests and exams used to find a disease in people who do not have any symptoms.

PurposeTo detect disease earlier than waiting for symptoms to develop.

ContextUsed in breast cancer screening to identify cancer before it causes symptoms.

inv-13: Mammogram

DefinitionA low-dose x-ray exam of the breasts used for detection and diagnosis of breast disease.

ModalityMammography is specialized medical imaging using a low-dose x-ray system.

Use casesScreening to find disease in asymptomatic women and diagnostic evaluation when indicated.

Background and Clinical Context

Mammography uses low-dose x-ray to detect breast disease early in asymptomatic women (screening) and to help diagnose breast disease when indicated. For screening, the policy recommends: ages 40–44: option to begin annual screening; ages 45–54: annual screening; age 55+: switch to biennial or continue annual screening, with continuation while the woman is in good health and has an expected life expectancy of at least 10 years. Additionally, two screening mammograms per year are covered when a physician recommends it for women treated for breast cancer within the past five years or for those at high risk (e.g., BRCA mutation, multiple first-degree relatives with breast cancer, high-risk lesion on prior biopsy, or atypical ductal hyperplasia).