CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Mammography (screening and diagnostic)

Covers Neighborhood Health Plan of Rhode Island coverage, documentation, coding, and reimbursement guidance for screening and diagnostic mammography for female members, including average- and high-risk scenarios.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMammography (screening and diagnostic)

Policy CodePolicy N/A

Change TypeNo material content changes (annual review 03/11/2024)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionVerify member eligibility, coverage, and any prior authorization requirements via the plan-specific Prior Authorization Reference page before scheduling.

SourceLink

POLICY UPDATE CHANGES

Annual policy review on 03/11/2024 with no content changes.

Content and format updates on 10/21/2021.

40-44optional annual screening

45-54recommended annual screening

55+switch to biennial or continue annual

2screening mammograms/year covered

77063,77067,77065,77066

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Coverage Criteria

inv-01: Screening Coverage Criteria

Covered screening mammography is described by age group and risk status when medical necessity is met.

Average-risk screening by age: Women 40-44 may opt for annual screening; women 45-54 should receive annual mammograms; women 55 and older may switch to biennial screening or continue annual screeningage-based

Applies to women considered at average risk (no personal history of breast cancer, no known high-risk genetic mutation such as BRCA, and no chest radiation before age 30)

High-risk or recent-treatment coverage: Two screening mammograms per year are covered when recommended by a physician for women treated for breast cancer within the last five years or who are at high risk due to genetic predisposition (e.g., BRCA mutation, multiple first-degree relatives) or prior high-risk lesions (e.g., lobular carcinoma in situ, atypical ductal hyperplasia)physician recommendation + risk factors

High-risk definitions and examples provided in policy

Women are not considered average risk for routine screening if they have any of the following: a personal history of breast cancer; a known high‑risk genetic mutation that increases breast cancer risk (for example, a BRCA gene mutation); or a history of chest radiation therapy before age 30. These situations are addressed under the policy's high‑risk guidance and may change recommended screening intervals and coverage (for example, eligibility for up to 2 screening mammograms per year when physician‑recommended).

Inclusion of a CPT code in this policy does not by itself guarantee coverage or reimbursement. Coverage is contingent on documented medical necessity and compliance with billing requirements; Neighborhood may request medical records and will deny or adjust payment for services that lack adequate documentation or appropriate coding per CMS and plan standards.

Covered Indications

inv-13: Screening for asymptomatic women by age and risk; Diagnostic for symptomatic evaluation or abnormal findings.

Indications for diagnostic mammography: Diagnostic mammography is indicated for evaluation of symptoms or abnormal screening findingsclinical indication

Diagnostic CPTs (77065/77066) apply

Coding and Frequency

Included CPT CodesCPT

77063	Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure).
77067	Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed.
77065	Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.
77066	Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.

inv-05: Screening frequency

Ages 40-44Optional annual screening mammography (patient may choose to begin annual screening)

Ages 45-54Annual screening mammography recommended (one per year)

Ages 55+May switch to biennial screening or continue annual mammography based on preference and clinical judgment

High-risk or recent treatmentUp to two screening mammograms per year covered when recommended by a physician for women treated for breast cancer within the last five years or at high risk

Provider Actions and Documentation

Prior Authorization

Verify eligibility and potential prior authorization

Providers must verify member eligibility, benefits, and any prior authorization requirements before rendering services. Verify coverage and prior authorization via Neighborhood Health Plan of Rhode Island plan-specific resources or by contacting Provider Services at 1-800-963-1001.

Check the plan-specific Prior Authorization Reference page before scheduling services.
Confirm member eligibility and coverage for the date of service.
Obtain prior authorization when required by the plan before providing non-emergent services.

Documentation Required

Required documentation and coding

Providers must maintain complete medical records that support the services billed and demonstrate medical necessity per CMS and Neighborhood standards. Documentation should reference applicable clinical criteria used to justify services (e.g., LCD, NCD, InterQual, EOHHS recommendations, or Neighborhood Clinical Medical Policies).

Frequency Limits

inv-14: Mammography (screening)

Typical frequencyScreening mammography: one per year is typical

Option for 55+Women 55 and older may switch to biennial screening or continue yearly screening

Additional annual examUp to two screening mammograms per year are covered when physician-recommended for high-risk patients or women treated for breast cancer within the last five years

Prior Authorization

Mammography prior authorization — verify per plan

Verify whether prior authorization is required for screening mammography under the member’s specific plan before scheduling; payer rules or referenced LCD/NCD may impose authorization requirements.

Check Neighborhood’s Prior Authorization Reference page for plan-specific requirements.

Contrast Rules

Billing Rule

Contrast billing rules

Follow documented billing and coding practices for contrast use in imaging per applicable coding and payer rules (no additional summary provided in policy).

Refer to payer-specific guidance or clinical policy documents for any contrast-related billing rules.

Definitions

inv-11: Screening vs Diagnostic Mammography

Screening mammographyImaging performed to detect breast disease in asymptomatic women; intended to find disease before symptoms occur

Diagnostic mammographyImaging performed to evaluate a breast problem or abnormal screening result (used for symptomatic evaluation or follow-up of abnormal findings)

Primary distinctionScreening is for asymptomatic population-level detection; diagnostic is targeted evaluation prompted by symptoms or abnormal screening

inv-12: Average risk

Definition of average riskNo personal history of breast cancer, no known high-risk genetic mutation (e.g., BRCA), and no chest radiation therapy before age 30

Implication for screening

Background

Mammography is a low‑dose X‑ray imaging modality used both for screening asymptomatic women to detect breast disease early and for diagnostic evaluation when there are symptoms or abnormal screening findings. Screening intervals and whether additional mammograms are covered depend on age and risk status.

Revision History

2024-03-11annual_reviewLatest

Annual policy review performed; no content changes noted.

2023-01-01annual_review

Annual policy review performed; no content changes noted.

2021-10-21content_format_update

Content and format updates applied to the policy.