LCD/NCD Portal

NCD220.4

 

MAMMOGRAMS

 

Effective Date of this Version

5/15/1978

 

Benefit Category

• Diagnostic Tests (other)

• Screening Mammography

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

• A diagnostic mammography is a radiologic procedure furnished to a man or woman with

o Signs and symptoms of breast disease.

o Personal history of breast cancer.

o Personal history of biopsy-proven benign breast disease, and includes a physician's interpretation of the results of the procedure.

• A screening mammography is a radiologic procedure furnished to a woman without signs or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s interpretation of the results of the procedure.

o A screening mammography has limitations as it must be, at a minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast.

 

Indications and Limitations of Coverage

• A diagnostic mammography is a covered service if it is ordered by a doctor of medicine or osteopathy as defined in §1861(r)(1) of the Act.

• Payment may not be made for a screening mammography performed on a woman under age 35.

o Payment may be made for only one screening mammography performed on a woman over age 34, but under age 40.

o For an asymptomatic woman over age 39, payment may be made for a screening mammography performed after at least 11 months have passed following the month in which the last screening mammography was performed.

• A radiological mammogram is a covered diagnostic test under the following conditions:

o A patient has distinct signs and symptoms for which a mammogram is indicated.

o A patient has a history of breast cancer.

o A patient is asymptomatic but, on the basis of the patient’s history and other factors the physician considers significant, the physician's judgment is that a mammogram is appropriate.

• Use of mammograms in routine screening of:

 Asymptomatic women aged 50 and over.

 Asymptomatic women aged 40 or over whose mothers or sisters have had the disease.

o Is considered medically appropriate, but would not be covered for Medicare purposes.

 

Cross Reference

• See the Medicare Benefit Policy Manual, Chapter 1, §50 and Chapter 15, §80.

 

CMS NCD220.4 MAMMOGRAMS