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Aetna Coverage for Mammogram


Aetna considers annual mammography screening a medically necessary preventive service for women aged 40 and older. Annual screening is also considered medically necessary for younger women who are judged to be at high- risk by their primary care physician. Screening mammography for other women is considered experimental and investigational because its benefits in these other women are unproven.

Aetna considers screening mammography for men experimental and investigational, as the clinical benefits of such screening in men are unproven. Current guidelines from the U.S. Preventive Services Task Force and the American College of Radiology recommend such screening only for women. Aetna considers mammography medically necessary for surveillance of men with a prior history of breast cancer.

Aetna considers diagnostic mammography medically necessary for members with signs or symptoms of breast disease or history of breast cancer.

Note: Diagnostic mammography is covered regardless of whether the member has preventive services benefits

Aetna considers digital mammography an acceptable alternative to film mammography.

Aetna considers computer-aided detection (CAD) a medically necessary adjunct to mammography.

Aetna considers xeroradiography for breast imaging experimental and investigational because this method of radiography is obsolete.

Aetna considers breast tomosynthesis imaging experimental and investigational because of insufficient evidence of its effectiveness

CPT codes covered if selection criteria are met:

+ 77051    Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure)
    
+ 77052    Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure)

77055    Mammography; unilateral

77056    Mammography; bilateral

77057    Screening mammography, bilateral (2-view film study of each breast)

HCPCS codes covered if selection criteria are met:

G0202     Screening mammography, producing direct digital image, bilateral, all views

G0204     Diagnostic mammography, producing direct digital image, bilateral, all views

G0206     Diagnostic mammography, producing direct digital image, unilateral, all views

ICD-9 codes covered if selection criteria are met:

174.0 - 174.9     Malignant neoplasm of female breast

198.81     Secondary malignant neoplasm of breast

217     Benign neoplasm of breast

233.0     Carcinoma in situ of breast

238.3     Neoplasm of uncertain behavior of breast

610.0 - 611.9     Disorders of breast

V10.3     Personal history of malignant neoplasm of breast

V16.3     Family history of malignant neoplasm of breast

V76.11     Screening mammogram for high-risk patient

V76.12     Other screening mammogram

Reference: http://www.aetna.com/cpb/medical/data/500_599/0584.html

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