CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 528.4.1

Mammography (Coverage Criteria)

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Defines West Virginia Medicaid coverage, requirements, and exclusions for screening and diagnostic mammography (including digital breast tomosynthesis) and related facility/provider requirements; applies to West Virginia Medicaid members and providers.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyMammography (Coverage Criteria)

Policy CodePolicy 528.4.1

Change TypeNo material change

Effective DateOct 1, 2024

Last ReviewOct 1, 2024

Next Review Date

Key ActionDocument the name of a physician in the record for screening mammography to receive results and provide follow-up.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/yrscreening mammography frequency limit

3D covered

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CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy 528.4.1

Mammography (Coverage Criteria)

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Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyMammography (Coverage Criteria)

Policy CodePolicy 528.4.1

Change TypeNo material change

Effective DateOct 1, 2024

Last ReviewOct 1, 2024

Next Review Date

Key ActionDocument the name of a physician in the record for screening mammography to receive results and provide follow-up.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/yrscreening mammography frequency limit

3D covered

Coverage Criteria and General Rules

Covered services

Covered when criteria below are met

Screening mammography coverage: Screening mammography is covered for members with no signs or symptoms of disease for the routine detection of breast cancer; limited to one per rolling year.1 per rolling year

Screening mammograms do not require a physician referral/order for coverage, but the name of a physician must be documented in the record to receive results and provide follow-up; digital breast tomosynthesis (3D) is covered for screening.

Diagnostic mammography coverage: Diagnostic mammography is covered for members exhibiting signs or symptoms or when abnormalities are suspected; digital breast tomosynthesis is covered for diagnostic use.

Physicians interpreting mammograms from MQSA-approved facilities may order diagnostic mammograms based on screening findings in accordance with 42 CFR 410.32.

Facility and reporting requirements: All facilities performing mammography must have FDA MQSA certification and be accredited by an FDA-approved accreditation body; mammography reports must include BI-RADS breast density information and members must be notified when applicable.MQSA certification and annual inspection

Non-compliant MQSA mammograms are not covered.

Non-covered services explicitly include non-compliant MQSA mammograms. Providers should note that any mammography performed by a facility that does not meet FDA MQSA requirements is listed as a non-covered service under this policy.

Non-compliant MQSA mammograms are not eligible for a West Virginia Department of Human Services (DoHS) Fair Hearing. The policy states that non-covered services, including non-compliant MQSA mammograms, are not eligible for DoHS Fair Hearing per 42 § 431.220.

Screening and Diagnostic Indications

Screening and diagnostic mammography indications

Screening indication: Asymptomatic members with no signs or symptoms of disease who require routine breast cancer detection; follow generally accepted clinical guidelines for initiation and frequency based on age and risk factors.1 per rolling year

Screening mammography may be performed using digital breast tomosynthesis.

Diagnostic indication: Members with signs or symptoms of breast disease or those with abnormal screening findings requiring further imaging evaluation; diagnostic mammography and tomosynthesis are covered for evaluation.

Physicians interpreting MQSA facility mammograms may order diagnostic mammograms based on screening findings per 42 CFR 410.32.

Coding, Frequency Limits and Regulations

Referenced regulationsmixed

No codes listed

inv-05: Screening mammography frequency — limited to one per rolling year

LimitScreening mammography is limited to one per rolling year

Applicable populationMembers with no signs or symptoms of disease (asymptomatic)

Modality allowedDigital breast tomosynthesis (3D) may be used for screening

Ordering requirementNo physician referral/order required for coverage, but physician name must be documented in the record

Ordering, Documentation and Provider Requirements

Prior Authorization

Ordering requirements for radiology services

A referring/treating Medicaid-enrolled provider must order all covered radiology services except screening mammography; screening mammograms do not require a physician order for coverage.

Step Therapy

Step therapy — not specified

No additional step-therapy requirements are specified in this policy for mammography services.

Documentation Required

Physician name documented for screening mammography

Key Definitions

inv-12: Screening Mammogram — definition and brief description

TermScreening Mammogram

DefinitionA mammogram routinely administered to detect breast cancer in members who have no apparent symptoms and includes a physician's interpretation of the results.

Coverage noteCovered for asymptomatic members; limited to one per rolling year; digital breast tomosynthesis may be used for screening.

inv-13: Diagnostic Mammogram — definition and brief description

TermDiagnostic Mammogram

DefinitionA mammogram performed on members that exhibit symptoms that may represent breast abnormalities including breast cancer; distinguished from screening by the presence of symptoms.

Service Frequency Limits

inv-16: mammography (screening) — one

Frequency limitOne screening mammogram per rolling year

ModalityIncludes digital breast tomosynthesis (3D) for screening

DocumentationPhysician name must be documented in the record to receive results and provide follow-up

Facility requirementFacility must have FDA MQSA certification and be accredited by an FDA-approved accreditation body

Prior Authorization Requirements

Prior Authorization

Screening mammography — no prior authorization required

Screening mammography does not require prior authorization and does not require a physician order for coverage; however, document the physician name in the record to receive results and provide follow-up.

Screening mammography is limited to one per rolling year.

Contrast Use and Billing Rules

Billing Rule

Contrast and related reporting — follow MQSA and accreditation standards

MQSA requirements and report content rules apply to contrast use and mammography reporting; follow MQSA and facility accreditation standards for any contrast-enhanced mammography procedures.

Ensure facility MQSA certification and adherence to MQSA-required reporting (including BI-RADS and breast density notifications).

Background and Purpose

Mammography services that fail to meet FDA Mammography Quality Standards Act (MQSA) requirements are classified as non-covered. This means exams performed at non-MQSA-compliant facilities will not be reimbursed and are explicitly called out in the policy’s non-covered services list.

Non-Covered Services

Non-compliant MQSA mammograms are listed under the policy’s non-covered services. Such exams are not covered by West Virginia Medicaid and are therefore excluded from coverage and appeal rights described for covered services.