Medical necessity for a diagnostic mammography

January 4th, 2018 - Find-A-Code
Categories:   Oncology|Hematology   Radiology  
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According to LCD L36342, a diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and symptoms of breast disease, personal history of breast cancer, or a personal history of biopsy-proven benign breast disease, and includes a physician’s interpretation of the results of the procedure. 

Diagnostic mammogram(s) are allowed for the following indications:

  • The patient is under the care of the referring/ordering physician or qualified non-physician practitioner;
  • There are signs and/or symptoms suggestive of malignancy (mass, some types of spontaneous nipple discharge or skin changes);
  • There are possible radiographic abnormalities detected on screening mammography;
  • There is short interval follow-up (less than one year) necessary for unresolved clinical/radiographic concerns; or 
  • Follow-up of established history of a malignancy is necessary

Diagnostic breast evaluation may be indicated in cases of a personal history of malignancy and in cases of benign biopsy-proven breast disease. These diagnoses should not, however, routinely warrant a diagnostic mammography.

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