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CIGNA Coverage for Mammography


CIGNA covers an annual screening mammography as medically necessary for ANY of the following indications:

Woman age 40 and over 

Woman age 25-39 when ANY of the following criteria are met: 
  1. history of prior high-dose thoracic irradiation (e.g., prior therapeutic radiation therapy) 
  2. a strong family history or genetic predisposition for breast cancer including ANY of the following: 
  • the individual has a known BRCA mutation 
  • a first-degree relative of BRCA carrier, but untested 
  • a five-year risk of invasive breast cancer = 1.7% as determined by a risk assessment tool based upon the modified Gail model (e.g., National Cancer Institute risk assessment tool) 
  • a lifetime risk of breast cancer > 20% as determined by a risk assessment tool such as BRCAPRO (i.e., Duke model) or other model that is largely dependent on family history (e.g., BOADICEA [Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm], Gail, Claus, or Tyrer-Cusick model) 
  • personal history of or a first-degree relative with Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome
CIGNA covers an annual mammography for surveillance of the affected and contralateral breast in an individual with a history of breast cancer as medically necessary.

CIGNA covers diagnostic mammography in males and females as medically necessary for ANY of the following indications:
 
•     abnormal or inconclusive screening mammography 
•     signs or symptoms of breast disease 
•     silicone gel-filled breast implant rupture is suspected 

CIGNA covers direct digital image production, for both screening and diagnostic mammography as medically necessary. 

CIGNA covers computer-aided detection when used as an adjunct to radiologist's interpretation as medically necessary, for both screening and diagnostic mammography. 

CIGNA does not cover digital tomosynthesis breast imaging including three-dimensional (3D) digital tomosynthesis (i.e., 3D mammography) because it is considered experimental, investigational or unproven.

CPT codes Covered when medically necessary:

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 (two view film study of each breast)

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

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

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

ICD-9-CM Diagnosis Codes

174.0-174.9      Malignant neoplasm of female breast

175.0-175.9      Malignant neoplasm of male breast

198.81  Secondary malignant neoplasm of breast

233.0      Carcinoma in situ of breast

610.0-610.9      Benign mammary dysplasia

611.0-611.9      Other disorders of breast

785.6  Enlargement of lymph nodes

793.80  Unspecified abnormal mammogram

793.81  Mammographic microcalcification

793.82  Inconclusive mammogram

793.89  Other (abnormal) findings on radiological and other examinations

V10.3  Personal history of malignant neoplasm of breast

996.54  Mechanical complication of other specified prosthetic device, implant, and graft, due to breast prosthesis  

V15.3  Personal history of irradiation

V16.3  Family history of malignant neoplasm, breast 

V76.11    Screening mammogram for high-risk patient

V76.12  Other screening mammogram

V84.01  Genetic susceptibility to malignant neoplasm of breast

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