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. For evaluation of breast lesion, identifying whether single or multi-focal, in individual with diagnosed breast cancer; For evaluation of suspicious mass, lesion, distortion or abnormality of breast in individual with history of breast cancer. For evaluation of identified lesion, mass or abnormality in breast in. We will work with the physician community through our Diagnostic Imaging Management Advisory Group to assure that there is no negative impact on the quality of patient care as a result of this initiative. http://www.breastcancer.org/symptoms/understand_bc/statistics BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. Most Florida Blue plans cover annual screening mammograms for women age 40 and older for as low as a $0 copay. Approve annually starting at age 30; Individuals not yet tested for BRCA gene, but with known BRCA mutation in first degree relative. We apologize for any inconvenience. 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. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Coverage Information. Originally published 11/16/2015; Revised 2019, 2022, Get News & Updates Directly To Your Inbox. Health Insurance Tax Information; Transparency in Coverage; Mental Health Parity; Teledentistry Services Covered; . However, some services like 3D imaging or ultrasounds may not be fully covered the same way. This is especially important for women who have dense breast tissue. A mammogram uses an X-ray to examine the breast tissue and can detect changes before you can feel them. Regular mammograms improve survival rates by 35% in women over 50. Privacy Policy Prior approval is required by all facilities or settings that offer outpatient, nonemergency diagnostic imaging services. Reimbursement Guidelines - Alphabetical Index, Reimbursement Guidelines - Categorical Index, Become a Blue Cross NC Provider or Recredential, Contact Information for Regional Network Management, Responsibilities of Primary Care Physicians (PCP) in 2008, IPP Coordination of Benefits Questionnaire. A follow-up study may be considered medically necessary to help evaluate an individual's progress after treatment, procedure, intervention or surgery. Mammograms are for older women. Fargo, N.D., 58121. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. You are viewing estimated values for an individual. Its important for adult women to have annual wellness exams after the age of 21. Doses, recommended ages and recommended populations vary. , SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Side-to-side and top-to-bottom images are made. Mammograms use very small doses of radiation and the risk of harm is very low. If there is a medical reason you cannot use a generic statin, your doctor should review this. There are many easy-to-use BMI calculators online, such as this example from the Centers for Disease Control and Prevention.*. All premiums listed represent coverage for dependents up to age 26. Yes. The remaining 40% are out-of-pocket costs. Learn more about our other insurance plans and Medicare plans, or contact a sales . This information is a reference tool and does not guarantee payment of any claims. Which health plans does the program apply to? (MAMMOGRAPHY) (Coverage Policy 2011018) USPSTF Recommendation. The goal of the diagnostic imaging program is to improve affordability of health care to Blue Cross NC members. Check your Benefit Booklet for details on other preventive care benefits. Under the Affordable Care Act (ACA), CareFirst and other health insurance carriers must cover a set of preventive serviceslike shots and screening testsand no cost to you. Annual physical exams and other preventive services are free when you use a Preferred . Members must enroll in the multi-call program to qualify for up to 12 weeks of NRT. Blue Shield of California is an independent member of the Blue Shield Association. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. To view this file, you may need to install a PDF reader program. Blue Cross and Blue Shield Association . Tissue doesnt overlap. What process is in place for unfavorable determinations? Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. To view this file, you may need to install a PDF reader program. Fraud and Abuse 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. 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. Issuance of a prior approval number is not a guarantee of payment. For example, women who have a family history of breast, cervical or ovarian cancer can be tested for the BRCA1 or BRCA2 genes. Here's how to interpret your BMI: Below 18.5: underweight. If so, it should not impact the ability of members to receive these tests. For women age 30-65. No coverage for oral contraceptive devices. Usage Agreement Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms. If you have questions about coverage for preventive services, . Understanding Health Care Costs and Quality, Provider Finder -Network Selection Criteria, HMO Provider Network Important Information, Making Your Health Insurance Work For You, Prescription Drug Changes and Pharmacy Information, Machine Readable Files for Transparency in Coverage. Scroll down to see some common services that may or may not be covered during a preventive care visit. Forgot User ID? Diagnostic mammograms more frequently than once a year, if medically necessary. If you don't see your insurance plan listed, please contact our Insurance Hotline at 469-398-4099 or email us at insuranceinfo@solismammo.com. This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs. 25 - 29.9: overweight. Currently, about 12% of women will develop breast cancer at some point in their lifetime. FDA-approved tobacco cessation prescription. recipe is no mess, no fuss and all flavor. The program will apply to members covered by the following plans: Blue Options SM (group PPO plan), Blue Option HRA (group PPO plan), Blue Options HSA (group and individual PPO plan), Classic Blue (Group CMM plan), Dental Blue (group and individual dental plan), Blue Advantage (individual PPO), Short Term Health Care (individual CMM plan). Data shows that roughly 30-40% of imaging exams are considered clinically inappropriate or noncontributory. 1 If you have gotten one dose of Zostavax vaccine for shingles, you should also get the two doses of Shingrix vaccine. Breast Cancer Mammography Screening Age 35-39 . Typical costs: For an uninsured patient, typical full-price cost of a mammogram ranges from $80 to $120 or more, with an average of about $102, according to Blue Cross Blue Shield of North Carolina. Olvido su contrasea? You are leaving this website/app ("site"). Mammograms arent as painful as you think you may feel a little pressure but it only lasts a few seconds. List of all medications that are covered at 100% onall formularies. As an example, women get regular mammograms at no cost to them as a preventive screening. Cancer screenings like colonoscopies and mammograms. For more information, view our privacy policy. The good news is that mammograms can catch cancer early, when its easiest to treat, even if you dont have any symptoms. About one in every seven or eight women gets it in her lifetime. Your doctor can help determine your risk level and what steps you should take. The diagnostic imaging management program impact is low; why did Blue Cross NC implement it? Fortunately, only about 1 in 400 people have a BRCA gene. These benefits are available for members of non-grandfathered individual health insurance plans. Should a member request Dynamic contrast material-enhanced MRI may be used to monitor response of a tumor to neoadjuvant chemotherapy used to shrink the tumor before surgery. Do practicing North Carolina physicians have input into the program? Out of network billing can lead to unexpected charges. Learn more about our non-discrimination policy and no-cost services available to you. Only ordering physicians can obtain a prior plan approval number. Combined together, the X-rays create a three-dimensional picture of each breast. Provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. We apologize for any inconvenience. When were Blue Cross NC's diagnostic imaging prior approval policies effective? Necesita su ID de usuario? Be sure you're taking full advantage of your coverage. You must be at least 18 years old to submit a request. Technical Information Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. Please update your browser if the service fails to run our website. Counseling. Talking with your healthcare provider about the . Learn more aboutmammogram screeningsin this video. When submitted, the claim will be processed in accordance with the terms of a subscriber's health benefit plan. Mammograms are one of the best ways to find it early. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. We recommend receiving estimates close to . Why did Blue Cross NC implement a diagnostic imaging management program? Annually about 220,000 women are diagnosed with breast cancer. Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities.
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