(2023) Aetna Coverage for Mammogram | CPT Codes, HCPCS Codes & ICD 10 Codes

Does Aetna cover mammograms? 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 judged 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 U.S. Preventive Services Task Force guidelines and the American College of Radiology recommend such screening only for women. Aetna considers mammography medically necessary to surveillance men with a prior history of breast cancer.

Aetna considers diagnostic mammography medically necessary for members with signs or symptoms of breast disease or a 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Aetna considers xeroradiography for breast imaging experimental and investigational because this radiography method is obsolete.

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

Aetna Covers The following CPT Codes If Selection Criteria Are Met

• CPT 77061: Digital breast tomosynthesis.
• CPT 77062: Digital breast tomosynthesis.
• CPT 77063: Screening digital breast tomosynthesis, bilateral [List separately in addition to code for primary procedure].
• CPT 77065: Diagnostic mammography, including computer-aided detection [CAD] when performed; unilateral.
• CPT 77066: Diagnostic mammography, including computer-aided detection [CAD] when performed; bilateral.
• CPT 77067: Screening mammography, bilateral [2-view study of each breast], including computer-aided detection [CAD] when performed.

HCPCS Code Covered By Aetna If Selection Criteria Are Met

HCPCS G0279: Diagnostic digital breast tomosynthesis, unilateral or bilateral [List separately in addition to 77065 or 77066].

ICD 10 Codes Covered By Aetna If Selection Criteria Are Met [Diagnostic] [Not All-Inclusive]

• ICD 10 codes covered if selection criteria are met [Diagnostic] [not all-inclusive]:
• ICD 10 C50.011: Malignant neoplasm of breast.
• ICD 10 C50.929: Malignant neoplasm of breast.
• ICD 10 C79.81: Secondary malignant neoplasm of breast.
• ICD 10 D05.00: Carcinoma in situ of breast.
• ICD 10 D05.92: Carcinoma in situ of breast.
• ICD 10 D24.1: Benign neoplasm of breast.
• ICD 10 D24.9: Benign neoplasm of breast.
• ICD 10 D48.60: Neoplasm of uncertain behavior of breast.
• ICD 10 D48.62: Neoplasm of uncertain behavior of breast.
• ICD 10 N60.01: Disorders of breast.
• ICD 10 N65.1: Disorders of breast.
• ICD 10 Q85.82: Other phakomatoses, not elsewhere classified [Cowden syndrome].
• ICD 10 Q85.83: Other phakomatoses, not elsewhere classified [Cowden syndrome].
• ICD 10 Q85.89: Other phakomatoses, not elsewhere classified [Cowden syndrome].

ICD 10 Codes Covered By Aetna If Selection Criteria Are Met For Screening Of Females [Not All-Inclusive]

• ICD 10 Z12.31: Encounter for screening mammogram for malignant neoplasm of breast.
• ICD 10 Z15.01: Genetic susceptibility to malignant neoplasm of breast [Li-Fraumeni syndrome].
• ICD 10 Z80.3: Family history of malignant neoplasm of breast.
• ICD 10 Z84.81: Family history of carrier of genetic disease.
• ICD 10 Z85.3: Personal history of malignant neoplasm of breast.
• ICD 10 Z86.000: Personal history of in-situ neoplasm of breast.
• ICD 10 Z92.3: Personal history of irradiation.

ICD 10 Codes Covered By Aetna If Selection Criteria Are Met For Screening Of Males

ICD 10 F64.8: Gender identity disorders [Transfeminine persons].
ICD 10 F64.9: Gender identity disorders [Transfeminine persons].
ICD 10 N62: Hypertrophy of breast.
ICD 10 Z15.01: Genetic susceptibility to malignant neoplasm of breast.
ICD 10 Z85.3: Personal history of malignant neoplasm of breast.
ICD 10 Z86.000: Personal history of in-situ neoplasm of breast.

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