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:
- history of prior high-dose thoracic irradiation (e.g., prior therapeutic radiation therapy)
- 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:
CPT 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)
CPT 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)
CPT 77055 Mammography; unilateral
CPT 77056 Mammography; bilateral
CPT 77057 Screening mammography, bilateral (two view film study of each breast)
CPT G0202 Screening mammography, producing direct digital image, bilateral, all views
CPT G0204 Diagnostic mammography, direct digital image, bilateral, all views
CPT G0206 Diagnostic mammography, producing direct digital image, unilateral, all views
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