blue cross blue shield mammogram coverage

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. Psychotherapy. Since being a carrier is relatively uncommon, doctors usually only test people with a family history of breast or ovarian cancer. 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. Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Coverage that is supplemental to Medicare but with no member cost Inconclusive screening mammogram due to breast characteristics limiting the sensitivity of mammography . Learn more about our non-discrimination policy and no-cost services available to you. The issue of return on investment and appropriateness of guidelines will be continually addressed as part of the evaluation of the program. There are significant concerns about patient safety involved in the increased exposure to radiation due to diagnostic imaging procedures. The cost estimate changed prior to your care. If you get benefits from your employer, you may also have these benefits. Routine health checkups. These benefits are currently in effect unless otherwise noted. Blue Shield of California is an independent member of the Blue Shield Association. 18.5 - 24.9: healthy weight. After your annual preventive exam, you will receive an Explanation of Benefits (EOB) from Blue Shield of California to notify you that your claim has been processed. One its drawbacks is breast tissue can overlap during compression. Mammogram screening $0 Once per year Nutrition therapy services $0 Ongoing if high risk Confirmation of silicone gel-filled breast implant ruptures, when this diagnosis cannot be confirmed by mammography or breast ultrasound; For postoperative evaluation of silicone breast implant complications. Most breast cancers are found in women 50 years old and older. Screening can help find breast cancer early, when it is easier to treat. Yes, as of September 1, 2010, all Blue Medicare HMO and Blue Medicare PPO members participate in the program. So why do so many women put off their mammograms? Privacy Policy Place of service exclusion: Sterilization coverage applies to all places of service, with the exception of the Emergency Room. Are you going to reimburse providers for the savings Blue Cross NC will incur? The AIM physician reviewer may contact the ordering physician to discuss the case in greater detail within two (2) business days of receipt of the request. Negotiated rates with providers can change, therefore, changing the estimate. 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. For example, at the Kapiolani Medical Center [ 1] in Aiea, Hawaii, where the full . If you have an HMO or POS plan, there are some additional services you'll need approval for. 0 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. Screening for high cholesterol is also covered at 100% every 5 years or annually for those with increased risk for CVD. Salpingectomy for sterilization purposes will be covered as preventive effective 7.1.22, Trans-dermal contraceptives (i.e., contraceptive patches), Diaphragms are available only through the pharmacy and IUDs are available only through a professional provider, If there is a medical reason you cannot take a generic contraceptive, your doctor should review this, Diaphragms, vaginal rings, contraceptive patches, female condoms, sponges, spermicides, and emergency contraception are available only with a prescription. Council and Blue Cross and Blue Shield of . Tobacco and alcohol use evaluations. We use cookies on this website to give you the best experience and measure website usage. 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. How should providers request prior approval? This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. When submitted, the claim will be processed in accordance with the terms of a subscriber's health benefit plan. Inconclusive screening mammogram due to breast characteristics limiting the sensitivity of mammography (e.g., extremely or heterogeneously dense breasts, implants); A breast cancer risk assessment (by the Gail risk or other validated breast cancer risk assessment models) that identifies the individual as having a lifetime risk of 20% or greater of developing breast cancer (approve annually); Two (2) or more first degree relatives (parents, siblings, and children) have history of breast cancer; Individuals with histories of extensive chest irradiation (usually as treatment for Hodgkin's or other lymphoma.) Its important for adult women to have annual wellness exams after the age of 21. The American Cancer Society recommends women ages 40 to 54 get annual mammograms, and women 55 and older get screenings every two years. Fargo (Headquarters) Echocardiography studies (effective for both Commercial and Blue Medicare HMO\PPO lines of business as of January 2, 2014), Member identification number, name, date of birth, and health plan, Imaging exam(s) being requested (body part, right, left or bilateral), Patient diagnosis (suspected or confirmed), Clinical symptoms/indications (intensity/duration), Results of treatment history (previous tests, duration of previous therapy, relevant clinical medical history), American Institute of Ultrasound in Medicine (AIUM), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) and National Coverage Determinations (NCD), Promoting and guiding the selection of the most appropriate and cost-effective diagnostic imaging services, Encouraging standardization of medical practice patterns and reducing variation in clinical evaluation, Curtailing the performance of inappropriate diagnostic imaging studies, Advocating biosafety issues, including reduction of clinical radiation exposure (for CT and plain film radiography), Enhancing quality of health care for diagnostic imaging studies using evidence-based medicine and outcomes research from numerous resources. Breast Screening Benefit "Diagnostic mammogram" means a mammogram obtained using diagnostic mammography . Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a.m. to 8 p.m. Eastern time. Which health plans does the program apply to? Approve annually starting at age 30; Individuals with known BRCA mutation. All rights reserved. Heres everything you need to know about it. By Regence. Please update your browser if the service fails to run our website. Heres a deeper dive on the potential benefits and risks of a 3D mammogram. 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. Bacteriuria screening for pregnant women. , SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. seen only in single view mammogram without ultrasound correlation); Previous positive breast biopsy within the previous four (4) months and no intervening previous breast MRI; Evaluation of palpable lesion on physical examination and not visualized on ultrasound or mammogram and MRI guided biopsy considered; For evaluation of axillary node metastasis or adenocarcinoma with normal physical examination and normal breast mammogram; Individuals diagnosed with biopsy-proven lobular neoplasia or atypical ductal hyperplasia (ADH); Personal history of or first-degree relative with Le-Fraumeni syndrome (TP53 mutation), Cowden syndrome (PTEN) or Bannayan-RileyRuvalcaba syndrome (BRRS). Please send us your question so a licensed agent can contact you. This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs. The diagnostic imaging management program guidelines are based on the most up-to-date recommendations of physician organizations such as the American College of Radiology and the American College of Cardiology. Regence supports women's preventive breast health. Breast cancer mammography screenings for women over age 40; Colorectal cancer screening for adults over age 45; . Most PDF readers are a free download. If eligible, you must receive genetic counseling and evaluation services before you receive preventive BRCA testing. Colorectal Cancer . Regular mammograms improve survival rates by 35% in women over 50. You are viewing estimated values for an individual. Evaluation of suspected breast cancer when other imaging examinations, such as ultrasound and mammography, and physical examination are inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g. Achieving this requires that we reduce the number of imaging examinations that do not add diagnostic value for members. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. BATON ROUGE - October is Breast Cancer Awareness Month. endstream endobj 105 0 obj <. 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. Should a member request Some buy into dangerous myths about breast cancer. "When a provider recommends getting screened, it indicates the risks outweigh the benefit and it is deemed to be safe," Dallow said, adding that under the . Check out the changes and updates to our plan in 2023. Genetic counseling and evaluation can help determine if youve inherited a BRCA mutation. Some preventive care services require that you meet . Forgot User ID? List of all medications that are covered at 100% onall formularies. It often forms in the tubes that carry milk to the nipple (ducts) and in glands that make milk (lobules). Routine gynecological visits. Immunizations for you and your family. All premiums listed represent coverage for dependents up to age 26. Heres everything you need to know about it. Lumps can be very difficult to feel on your own, which is why its recommended that women over the age of 40 receive regular mammograms. TheU.S. Preventive Services Task Forcerecommends that women between the ages of 50 and 74 get a mammogram every two years. Women ages 35-39 can receive one baseline mammogram(four views). Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a.m. to 8 p.m. Eastern time. If so, it should not impact the ability of members to receive these tests.

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