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Aetna considers xeroradiography for breast imaging experimental and investigational because this method of radiography is obsolete.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