Bronze Standard - Individual & Family Health Plans 2021 - BCBSWNY Reimbursement Policy: Screening and Diagnostic Mammography & 3D Tomosynthesis Effective Date: April 15, 2017 Last Reviewed Date: February 14, 2023 Purpose: Provide guidelines for the processing of claims for multiple mammograms, CAD and Digital Breast Tomosynthesis (DBT) to align with recent changes to CMS' position on screening and diagnostic mammograms and to define what a mammographic . We apologize for any inconvenience. The protection of your privacy will be governed by the privacy policy of that site. Usage Agreement Click on a service to see any limits or exclusions. Cat-scan technology exposes patients to more radiation than an X-rays. Provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. Make sure to get all the screenings and vaccines recommended for your age and gender. Women between the ages of 40 and 49 should talk to their doctor about when they should start getting mammograms. Member Coverage | BlueCross BlueShield of Vermont Blue Cross Blue Shield of Massachusetts also offers insurance, pharmacy coverage, and Medicare Plans for seniors; life and disability insurance through Indigo Insurance Services (a wholly owned subsidiary); and insurance for individuals aged 18-26 years. It is important to note that these services are free only when delivered by a doctor or other . What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. Insurance. According to the American Cancer Society, our state lags behind much of the nation in mammography screenings. Originally published 11/16/2015; Revised 2019, 2022, Get News & Updates Directly To Your Inbox. Who can physicians call if they have questions? Mammograms: Early detection saves lives | Coverage - Blue Cross Blue Women ages 40 and older can receive a mammogram (four views) each calendar year. Frequently Asked Questions: Mammograms - Blue Cross Blue Shield of Ordering physicians may also contact the AIM physician reviewer at any time during the authorization process. . To learn if your patient's plan requires prior approval for these services, please reference the diagnostic imaging procedures page. A follow-up study may be considered medically necessary to help evaluate an individual's progress after treatment, procedure, intervention or surgery. Routine gynecological visits. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. The average mammogram appointment is just 15 minutes long. Side-to-side and top-to-bottom images . If you discuss new medical concerns or a current illness, the entire visit may be considered a medical treatment visit and would not be covered as preventive care. Learn more about our non-discrimination policy and no-cost services available to you. . Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. There are significant concerns about patient safety involved in the increased exposure to radiation due to diagnostic imaging procedures. We have an obligation to our members to provide quality care at an affordable price. Know the Difference Between a Preventive and Diagnostic - Florida Blue How does Blue Cross NC ensure that the program does not negatively impact patient care, divert physicians from the practice of medicine or compromise the patient/physician relationship? Non-Discrimination Statement and Foreign language Access. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. Issuance of prior approval is not a guarantee of payment. (MAMMOGRAPHY) (Coverage Policy 2011018) USPSTF Recommendation. In fact, we rank 32nd out of 50 states. Mammograms are a key component of a womens preventative care. What imaging procedures do NOT require prior approval? Blue Shield of California 1999 . How should providers request prior approval? No prescription medication or NRT limit when received via pharmacy benefit, Tetanus-Diphtheria/Tetanus-Diphtheria Acellular Pertussis (Tdap). This new site may be offered by a vendor or an independent third party. Fargo (Headquarters) Discover all the ways members can earn wellness incentives and rewards for taking an active role in their health. If you have a higher risk for breast cancer, talk to your doctor about screening, no matter how old you are. One option is Adobe Reader which has a built-in screen reader. A high BMI can be a warning sign for potential health problems. Support Transgender services | Blue Cross Blue Shield of Massachusetts If you had a polyps removed during a previous preventive screening colonoscopy, future colonoscopies will be covered but may not be considered preventive so you may have out of pocket costs. listed below will be covered by your plan. All rights reserved. They can help detect breast cancer up to three years before it can be felt. But a damaged or broken gene can increase the risk of developing breast cancer. New health problems discussed with your doctor during your visit, Diagnoses that need to be addressed such as high blood pressure, diabetes, skin rash, and headaches, Breast cancer mammography screenings for women over age 40, Colorectal cancer screening for adults over age 45, Cholesterol screening for adults of certain ages or at higher risk, Additional testing and follow-up procedures if abnormalities are found during mammography or colorectal cancer screenings, Request for a vitamin Dlevel check to test for bone and muscle development and function, Request for a vaccination filter test to determine acceptable amounts of vaccine antibodies in the bloodstream. You usually need to get tested every 3 to 5 years. Blue Cross and Blue Shield Association . Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. , SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 122 0 obj
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Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. If eligible, you must receive genetic counseling and evaluation services before you receive preventive BRCA testing. All Rights Reserved. . If there is a medical reason you cannot use a generic statin, your doctor should review this. The policies were effective for diagnostic imaging services performed on or after February 15, 2007 for Blue Cross NC commercial plans. You should get screenings every one or two years, depending on your doctor's advice. FDA-approved tobacco cessation prescription. Talk to your doctor to find out which of these you should have based on your health. For preoperative evaluation for known breast cancer when surgery planned within thirty (30) days; Evaluation of more than two (2) lesions to optimize surgical planning when requested by surgeon or primary care provider on behalf of surgeon who has seen the individual. mammogram for women between ages 35-39. Breast cancer mammography screenings for women over age 40; Colorectal cancer screening for adults over age 45; . Immunizations for you and your family. MRI of the breast may be considered medically necessary for individuals with silicone implants whenEITHERof the following are met: MRI of the breast may be considered medically necessary for individuals with no history of known breast cancer, MRI of the breast may be considered medically necessary for individuals with history of known breast cancer. This can get confusing, so call your health plan before you go. Regular mammograms improve survival rates by 35% in women over 50. Call us at 1-888-243-4420 if you have questions or need help. Discover all the ways members can earn wellness incentives and rewards for taking an active role in their health. $100 outpatient benefits. This information is a reference tool and does not guarantee payment of any claims. Blue Cross and Blue Plus plans cover these eligible preventive services for women ages 12-64, with no member cost sharing when obtained at the in-network level*: Alcohol and substance misuse counseling. MRI of the breast is a useful tool for the detection and characterization of breast disease, assessment of local extent of disease, evaluation of treatment response, and guidance for biopsy and localization. What process is in place for unfavorable determinations? Most basis mammogram screenings are covered by your health plan. What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. The goal of the diagnostic imaging program is to improve affordability of health care to Blue Cross NC members. %%EOF
Understand the difference between preventive and diagnostic. Internal Medical Policy Committee 11-19-2020 Annual Review-Title changed slightly, Internal Medical Policy Committee 11-23-2021 Annual Review-no changes in criteria, Internal Medical Policy Committee 11-29-2022 Annual Review-no changes in criteria. 2023 Blue Cross and Blue Shield of North Carolina. Tissue doesnt overlap. Screenings, tests and other preventive care services Preventive care service Cost . Ho Chi Minh City Hotels | Find & compare great deals on trivago Routine health checkups. . Many travel vaccines are not covered including: Your doctor will determine what tests or health screenings are needed based on your age, gender, and overall health status. The U.S. Preventive Services Task Force currently recognizes both 2D and 3D mammography as equally acceptable screening methods. Forgot User ID? The site may also contain non-Medicare related information. Screening for high cholesterol is also covered at 100% every 5 years or annually for those with increased risk for CVD. During your visit, your doctor will perform a clinical breast exam. Fargo, N.D., 58121. Telligent is an operating division of Verint Americas, Inc., an independent company that provides and hosts an online community platform for blogging and access to social media for Blue Cross and Blue Shield of Illinois. Description: Screening for cervical cancer. Annual physical exams and other preventive services are free when you use a Preferred . The age and frequency listed below are general recommendations. Blue Cross NC created a Diagnostic Imaging Advisory Group, which includes North Carolina physicians who order and render radiology services and representatives of major medical organizations, to allow for medical community feedback. A mammogram uses an X-ray to examine the breast tissue and can detect changes before you can feel them. "Screening" means checking a woman's breasts for cancer before there are signs or symptoms of the disease present. 2 The HPV vaccine (Gardasil) is covered to age 45 per the Food and Drug Administration (FDA) guidelines. When it's preventive: You get a mammogram to check for breast cancer. Blue Cross and Blue Shield Service Benefit Plan brochures, https://www.mayoclinic.org/tests-procedures/brca-gene-test/about/pac-20384815. Does Blue Cross Blue Shield cover annual mammograms? - Answers Based on clinical criteria, AIM will issue a prior approval number or will forward requests to a nurse or physician if they require further review. Anesthesia and pathology from polyps found during a screening colonoscopy is covered at 100%. Please utilize the checklist below as a guideline to ensure you have all the necessary information before requesting prior approval: For complex cases, more information may be necessary, including: The diagnostic imaging management process is based upon AIM clinical practice guidelines, developed from consensus opinion in medical practice and integration of medical information from multiple sources, including: The prior approval number will be valid for 30 days from the date issued - not the date of service requested. Best Answer. BATON ROUGE - October is Breast Cancer Awareness Month. To capture them, the breast is pulled away from the body, compressed and held between two glass plates. Mammograms arent as painful as you think you may feel a little pressure but it only lasts a few seconds. Heres a deeper dive on the potential benefits and risks of a 3D mammogram. Screening mammograms every 12 months if you are a woman age 40 or older. External link You are leaving this website/app (site). HMO coverage is offered by Health Options, Inc. DBA Florida Blue HMO. There are also additional guidelines if you're pregnant. The American Cancer Society recommends women ages 40 to 54 get annual mammograms, and women 55 and older get screenings every two years. Preventive Care for Women | Blue Cross NC It happens in both men and women, but breast cancer in men is not common. Blue Cross NC is the fourth insurer in the state to implement a diagnostic imaging management program, and we understand that our physician community has vital feedback that will help make our program successful. hbbd``b` What information is required to request prior approval? Under the benefits of certain plans, the following diagnostic imaging services that are received in an outpatient setting, such as in a medical office, the outpatient department of a hospital or at a freestanding imaging center may require prior approval (for dates of service on or after February 15, 2007 for Blue Cross NC commercial plans and September 1, 2010 for Blue Medicare HMO and Blue Medicare PPO plans): Prior approval is not required when these procedures are performed in an emergency room, hospital (related to an inpatient or observation stay), urgent care center or ambulatory surgical center. Find an in-network doctor for preventive care. Check your Benefit Booklet for details on other preventive care benefits.