Aetna Mammography coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Screening mammography: annual mammography screening is considered medically necessary as a preventive service for women aged 40 years and older.
• Screening mammography for high-risk younger women: annual mammography is considered medically necessary for women younger than 40 who are at high risk, meeting ANY ONE of the following: (a) known BRCA1 or BRCA2 mutation carrier; OR (b) meet criteria for BRCA mutation testing per CPB 0227; OR (c) personal diagnosis of, or a first-degree relative with, Bannayan-Riley-Ruvalcaba syndrome, Cowden syndrome, or Li-Fraumeni syndrome; OR (d) personal history of chest/thoracic radiation therapy received between ages 10 and 30 years.
• Screening mammography for BRCA-positive men with gynecomastia: annual screening mammography is considered medically necessary for BRCA-positive men with gynecomastia, beginning at age 50 years OR 10 years before the earliest known male breast cancer in the family, whichever is earlier.
• Screening mammography for transfeminine persons: annual screening mammography is considered medically necessary for transfeminine persons aged 40 years and older with 5 or more years of past or current feminizing hormone use.
• Diagnostic mammography: considered medically necessary for members (women and men) with signs or symptoms of breast disease or a history of breast cancer. Diagnostic mammography is covered regardless of whether the member has preventive services benefits.
• Digital mammography is considered an acceptable medically necessary alternative to film (screen-film) mammography.
• Digital breast tomosynthesis (3D mammography) is considered an acceptable medically necessary alternative to standard 2D mammography.
• Computer-aided detection (CAD) is considered a medically necessary adjunct to mammography.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 77065·PA verdict·Rate
• 77066·PA verdict·Rate
• 77067·PA verdict·Rate

Frequently asked questions

When does Aetna cover Mammography (CPT 77065), and what gets it denied?

Aetna CPB 0584 covers annual screening mammography for average-risk women aged 40 and older, and earlier/expanded screening for high-risk groups (BRCA carriers, certain hereditary syndromes, prior chest radiation, BRCA-positive men with gynecomastia, and transfeminine persons 40+ on long-term hormone therapy), plus diagnostic mammography for anyone with breast signs/symptoms or breast-cancer history regardless of benefit status. Digital mammography, 3D tomosynthesis, and computer-aided detection are accepted, while AI-based mammography, contrast-enhanced mammography for screening, low-dose CT combined imaging, general male screening, and xeroradiography are not covered. The key gate is medical necessity tied to age, risk stratification, gender-affirming status, and presence of symptoms. Coverage criteria include: Screening mammography: annual mammography screening is considered medically necessary as a preventive service for women aged 40 years and older.; Screening mammography for high-risk younger women: annual mammography is considered medically necessary for women younger than 40 who are at high risk, meeting ANY ONE of the following: (a) known BRCA1 or BRCA2 mutation carrier; OR (b) meet criteria for BRCA mutation testing per CPB 0227; OR (c) personal diagnosis of, or a first-degree relative with, Bannayan-Riley-Ruvalcaba syndrome, Cowden syndrome, or Li-Fraumeni syndrome; OR (d) personal history of chest/thoracic radiation therapy received between ages 10 and 30 years.; Screening mammography for BRCA-positive men with gynecomastia: annual screening mammography is considered medically necessary for BRCA-positive men with gynecomastia, beginning at age 50 years OR 10 years before the earliest known male breast cancer in the family, whichever is earlier.; Screening mammography for transfeminine persons: annual screening mammography is considered medically necessary for transfeminine persons aged 40 years and older with 5 or more years of past or current feminizing hormone use.; Diagnostic mammography: considered medically necessary for members (women and men) with signs or symptoms of breast disease or a history of breast cancer. Diagnostic mammography is covered regardless of whether the member has preventive services benefits.; Digital mammography is considered an acceptable medically necessary alternative to film (screen-film) mammography.; Digital breast tomosynthesis (3D mammography) is considered an acceptable medically necessary alternative to standard 2D mammography.; Computer-aided detection (CAD) is considered a medically necessary adjunct to mammography.. Applies to 3 codes: 77065, 77066, 77067. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Artificial intelligence (deep learning / machine learning)-based mammography for diagnosis or screening of breast cancer is considered experimental, investigational, or unproven.; Contrast-enhanced mammography (CEM) for breast cancer screening (whether used alone or in combination with tomosynthesis) is considered experimental, investigational, or unproven.; Low-dose CT combined with mammography for the diagnosis of overflow breast disease (breast nipple discharge) is considered experimental, investigational, or unproven.; Screening mammography for men is considered not medically necessary, except for BRCA-positive men with gynecomastia and transfeminine persons as specified in the medically necessary criteria; the clinical benefits of such screening in men are unproven.; Screening mammography for women not included in the medically necessary criteria (Section I) is not covered; the benefits of screening mammography in other women are unproven.; Xeroradiography for breast imaging is not covered as it is considered an obsolete method. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Mammography?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.

What does Aetna exclude for Mammography?

Policy exclusions and limitations: Artificial intelligence (deep learning / machine learning)-based mammography for diagnosis or screening of breast cancer is considered experimental, investigational, or unproven.; Contrast-enhanced mammography (CEM) for breast cancer screening (whether used alone or in combination with tomosynthesis) is considered experimental, investigational, or unproven.; Low-dose CT combined with mammography for the diagnosis of overflow breast disease (breast nipple discharge) is considered experimental, investigational, or unproven.; Screening mammography for men is considered not medically necessary, except for BRCA-positive men with gynecomastia and transfeminine persons as specified in the medically necessary criteria; the clinical benefits of such screening in men are unproven.; Screening mammography for women not included in the medically necessary criteria (Section I) is not covered; the benefits of screening mammography in other women are unproven.; Xeroradiography for breast imaging is not covered as it is considered an obsolete method. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT