Coverage Policies

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

c)     QualChoice preventive health benefits are intended for the early detection and/or treatment of diseases by screening for their presence in an individual who has neither symptoms nor findings suggestive of those diseases.

a.     For example, tests performed for the following reasons are not considered to be screening tests:

                                                    i.     Investigating a symptom;

                                                   ii.     Investigating an abnormal finding on physical examination, or in a laboratory or imaging test;

                                                 iii.     Testing to rule out or confirm the presence of a diagnosis suggested by symptoms or abnormal findings in physical examination, laboratory or imaging tests;

                                                 iv.     Testing to assess the status or progress of a diagnosed problem;

                                                  v.     Testing to check for the recurrence of a disease previously diagnosed and treated.

b.     Many services are NOT covered as part of the preventive health screening benefit because they are not recommended by the United States Preventive Services Task Force (USPSTF) for this use. These tests may be covered under the standard medical benefit, in accordance with standard medical benefit rules, when they are used to investigate abnormal findings in the history or physical examination or to make or confirm a diagnosis or to gather follow-up information after treatment of a medical condition. Examples:

                                                    i.     Chest x-rays.

                                                   ii.     Electrocardiograms.

                                                 iii.     Treadmill (exercise) cardiograms.

d)    QualChoice covers preventive health services as detailed in the member’s health benefit plan coverage document. Reference to the member’s coverage documents and benefit summary is necessary to determine specific preventive health benefit coverage. The Enrollee should be aware of special benefits, limits, and/or restrictions on preventive treatments, in particular whether the service is obtained out of network. 

NOTE:  The way that your physician submits a claim for services may affect the way the claim is paid.  We will only consider a particular service to be preventive if the physician bills that service with a diagnosis that describes a preventive service, as defined below.

QualChoice pays radiologists who obtain an additional interpretation of mammograms by computerized readings.

1)    QualChoice believes that a well-designed, evidence-based health maintenance program is an important benefit to our members and cost-effective for premium payers.

2)    QualChoice has adopted the preventive testing recommended by the US Preventive Service Task Force of the Agency for Healthcare Research and Quality in the Department of Health and Human Services as a standard benefit, as well as the Bright Futures Periodicity Table Recommendations.

3)    There may be a limit on the preventive medicine benefit (the amount may vary from plan to plan) in other plans as well. This means that careful and conservative use of this benefit is essential to be sure that all patients receive the maximum benefit from this coverage.

4)      QualChoice is publishing this policy in order to have the coverage rules spelled out as explicitly as possible. CPT codes 77065 – 77067 are for mammography that includes CAD (Computer Aided Detection), if done. These codes include the process of digitizing the image and a computerized “read” of the digitized images – constituting a “second reading” which increases the accuracy of the mammogram.

5)    Breast Digital Tomosynthesis (3D digital mammogram) [77061-77063] is covered for CHI and risk plans.

6)    Screening Digital Breast Tomosynthesis [77063] is covered once every 12 months as a preventive benefit.

7)    Digital Breast Tomosynthesis (DBT) [77061 – 77062] is covered under the medical benefit when billed with any of the following diagnosis codes:

·         C50.011 – C50.929 (Malignant neoplasm of breast),

·         C79.81 (Secondary malignant neoplasm of breast),

·         D05.00 – D05.92 (Carcinoma in situ of breast),

·         D24.1 – D24.9 (Benign neoplasm of breast),

·         D48.60 – D48.62 (Neoplasm of uncertain behavior of breast),

·         R92.0 – R92.8 (Abnormal/inconclusive findings on breast imaging)

·         N60.01 – N65.1 (Disorders of breast).

8)    Breast ultrasounds [76641 – 76642]

a)    The use of ultrasound for routine breast cancer screening is considered experimental and investigational, and is not covered. 

b)    Breast ultrasound is covered under preventive benefit when it is performed as an adjunct to screening mammography for dense breast tissue or masses found on mammogram.

9)      Automated Whole Breast Ultrasounds (AWBUS) are considered Experimental and Investigational and therefore are not covered.

Codes Used in This BI:

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail.  State and federal mandates will be followed as they apply.