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77063

PAYER POLICY CHANGES

77063 Insurance Policy Changes

CPT 77063, in plain terms, covers Add-on screening 3D breast tomosynthesis of both breasts, reported in addition to the screening mammogram. CPT 77063 is referenced in 18 tracked payer policy changes from Blue Cross Blue Shield of Vermont, Utah Medicaid, and 11 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 77063 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 77063 on AAPC

Blue Cross Blue Shield of Vermont · Effective Dec 1, 2026High impact
Preventive Care Reminder Sent to Members
Members receive the preventive services listed here at no cost when they align with USPSTF A- and B-rated services, ACIP vaccine recommendations, HRSA infant, child, adolescent and women's preventive guidelines, and Vermont state mandates. Covered procedure and diagnosis codes are listed for screenings, counseling, vaccines and preventive medications for children, adults and pregnant members, and some services require prior approval. Recent revisions add a Pre-Diabetes Preventive Interventions section for adults 18 and older, split mammography into diagnostic, ultrasound and MRI sections, and add pregnancy diagnosis codes effective 12/01/2026.
Utah Medicaid · Effective Jul 1, 2026High impact
July 2026 Medicaid Information Bulletin
Unless otherwise noted, Utah Medicaid changes in July 2026 take effect July 1, 2026. Telehealth services require modifier 93 or 95 beginning October 1, 2026, and several behavioral health codes and revenue code reporting change in January 2027. Other changes cover provider revalidation and enrollment, dental claims moving from managed care to fee-for-service, custom tracheostomy tube billing, and behavioral health code rates.
Humana · Effective Jul 1, 2026High impact
Breast Imaging - Medicare Advantage (Revised)
This is a revised Medicare Advantage policy for breast imaging (effective 07/01/2026) that establishes coverage criteria for mammography, digital breast tomosynthesis, breast MRI, and ultrasound. The policy clarifies medical necessity requirements and references applicable Local Coverage Determinations (LCDs) by MAC jurisdiction. Billing teams must verify which MAC jurisdiction applies to their geographic location to determine specific coverage rules.
BlueCross BlueShield of South Carolina · Effective May 29, 2026High impact
2026 May Medical Policy Updates
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 40 updated medical policies effective May 29, 2026. Most are routine annual reviews with no policy intent changes. Key billing updates include: new CPT codes 77062-77063 for breast cancer screening, replacement of CPT 99401-99402 with HCPCS S9943 for breastfeeding counseling, new compression pump CPT codes E0658/E0678-E0683 for lymphedema treatment, new CPT 0423U for pharmacogenetic testing, addition of HDR prostate brachytherapy as salvage therapy, new corneal collagen cross-linking products covered, and deletion of radiation therapy codes G6015-G6016.
BlueCross BlueShield of South Carolina · Effective May 29, 2026High impact
2026 May Medical Policy Updates
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 40 medical policy updates effective May 29, 2026. Key billing changes include: (1) CPT codes 77062 and 77063 added for breast cancer screening; (2) HCPCS code S9943 replaces CPT codes 99401/99402 for breastfeeding counseling; (3) Seven new E-series codes (E0658, E0678-E0683) added for compression pumps; (4) CPT code 0423U added for pharmacogenetic testing; (5) One new policy (CAM 404) for Transcranial Magnetic Stimulation; (6) CAM 80133 expanded to include HDR temporary prostate brachytherapy as salvage therapy; (7) CAM 80160 reorganized criteria for ECMO; (8) CAM 90328 expanded to include epithelium-on corneal collagen products.
Colorado Medicaid · Identified Jul 1, 2026High impact
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600540 - 07/2026)
A 2% across-the-board Health First Colorado provider rate reduction applies to dates of service beginning July 1, 2026, with exemptions for managed care, pharmacy, RHCs, FQHCs, pediatric behavioral therapy, select NICU and neonatal services, select maternity services, and family planning services. Procedure codes 97535 and 97537 are no longer covered as of July 1, 2026, and CPT 77063 became a covered benefit that must be billed on the same claim as CPT 77067. Effective August 1, 2026, PT 25 and PT 16 claims will be denied when billed for certain behavioral health supportive and team-based services in fee-for-service or to the Regional Accountable Entities.
Humana · Effective Jul 1, 2026Medium impact
Breast Imaging - Medicare Advantage (Revised)
This is a revised Medicare Advantage breast imaging coverage policy (effective 2026-07-01) that establishes medical necessity criteria for mammography, digital breast tomosynthesis, breast MRI, and ultrasound across Humana plans. The policy clarifies screening breast MRI eligibility based on genetic variants, family history, lifetime risk assessment (≥20%), male breast cancer history, or prior chest radiation. Billing teams must verify current applicability and confirm whether this practice's billing workflows align with the specified coverage criteria and applicable MAC jurisdictions.
BlueCross BlueShield of South Carolina · Effective May 29, 2026Medium impact
2026 May Medical Policy Updates
BlueCross BlueShield of South Carolina updated 35 medical policies in May 2026, with key billing code changes for breast cancer screening and breastfeeding counseling, expanded coverage for lymphedema compression pumps, new salvage therapy coverage for prostate cancer, and introduction of a new Transcranial Magnetic Stimulation policy.
Florida Blue · Effective Apr 1, 2026Medium impact
Accurate Documentation Optimizes Health Outcomes and More
Florida Blue emphasizes the importance of accurate documentation using specific CPT II and ICD-10 codes for HEDIS quality measures including statin therapy, diabetic eye exams, cancer screenings, and flu vaccinations. This policy focuses on proper coding and documentation practices to improve patient outcomes and HEDIS scores.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2025Medium impact
Digital Breast Tomosynthesis
Screening digital breast tomosynthesis (CPT 77063) is covered once per calendar year as an alternative to standard 2D mammography for women beginning at age 35, as part of the Healthy You! Wellness benefit, effective 01/01/2018. Digital breast tomosynthesis may be considered medically necessary as an alternative to standard 2D mammography for further imaging when used for breast cancer diagnostic purposes. Already effective 2025-10-01: ICD-10 diagnosis codes C50.A0, C50.A1 and C50.A2 for malignant neoplasm of breast were added to the code reference.
Highmark · Effective Sep 29, 2025Medium impact
Breast Cancer Awareness Month: Tips for Rescheduling Patients before January
This is a provider outreach bulletin from Highmark encouraging practices to reschedule patients who missed breast cancer screening appointments during October (Breast Cancer Awareness Month) to close HEDIS BCS-E measure gaps. The policy identifies specific mammogram CPT codes and mastectomy codes that count toward the screening measure for members ages 50-74, with measurement period Oct 1, 2023 through Dec 31, 2025.
Aetna · Identified Oct 5, 2026Medium impact
Mammography (CPB 0584, reviewed 2026-09-10)
Annual screening mammography is medically necessary for women aged 40 and older as a preventive service, and for women under 40 who are judged to be at high risk, such as BRCA1 or BRCA2 mutation carriers. Diagnostic mammography is covered for members with signs or symptoms of breast disease or a history of breast cancer, whether or not they have preventive benefits. AI-based mammography, contrast-enhanced mammography for members who do not meet the medical necessity criteria, and screening mammography in men outside the listed indications are considered experimental, investigational or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Mammography (CPB 0584, reviewed 2025-09-09)
Aetna considers annual screening mammography medically necessary as a preventive service for women aged 40 and older, and for women under 40 who are judged to be at high risk, such as BRCA1 or BRCA2 mutation carriers and women meeting the other listed risk criteria. Diagnostic mammography is covered for members with signs or symptoms of breast disease or a history of breast cancer, regardless of whether the member has preventive benefits. Digital mammography and digital breast tomosynthesis are acceptable alternatives to film and standard 2D mammography, computer-aided detection is a medically necessary adjunct, and contrast-enhanced mammography is covered only for high-risk members who meet breast MRI criteria but have a documented contraindication, intolerance, or lack of access.
Aetna · Identified Aug 14, 2026Medium impact
Breast Biopsy Procedures (CPB 0269, reviewed 2026-05-14)
Aetna considers MRI-guided core needle biopsy, radioactive seed localization (RSL), radio-guided occult lesion localization (ROLL), stereotactic guided core needle biopsy, ultrasound-guided core needle biopsy, and vacuum-assisted core-needle biopsy medically necessary alternatives to needle localization core surgical biopsy when breast abnormalities seen on mammography, ultrasound or breast MRI are non-palpable or difficult to palpate and are suspicious or highly suggestive of malignancy (BI-RADS category 4 or 5). Digital breast tomosynthesis-guided breast biopsy is considered an equally acceptable alternative to mammographically guided biopsy for medically necessary indications. The following are considered experimental, investigational or unproven: the pegulicianine (Lumisight) fluorescence-guided system, other minimally invasive image-guided breast biopsy procedures not listed as covered (such as PET-guided breast biopsy [Naviscan]), 3D volumetric imaging and reconstruction of breast or axillary lymph node tissue, tomosynthesis-guided placement of radiofrequency identification (RFID) localizer tags, magnetic seeds (e.g., Magseed) and the SAVI SCOUT surgical guidance system during localized excisional biopsy or lumpectomy, and the MarginProbe for intra-operative margin assessment during breast surgery.
NY Medicaid · Identified Jun 30, 2026Medium impact
New York State Medicaid Coverage of Breast Cancer Screening, Imaging, and Testing for Management and Treatment
NYS Medicaid fee-for-service and Medicaid Managed Care cover breast cancer screening and diagnostic imaging with no cost-sharing to the patient, as the New York State Breast Cancer Screening Law requires. Coverage includes diagnostic mammograms, breast ultrasound, and MRI when ordered by a provider in accordance with nationally recognized clinical guidelines. Mammography alone is the recommended and preferred screening modality for most people, and MRI should not replace mammography. Coverage criteria also apply to tomosynthesis, breast biopsy, BRCA1 and BRCA2 testing, and predictive and prognostic breast cancer assays.
Alaska Medicaid · Identified Jun 21, 2026Medium impact
July 2024 Town Hall FAQ
Alaska Medicaid issued a Town Hall FAQ addressing current operational issues including claims data entry errors, primary/secondary payment processing problems, and updated contact information for service authorizations and appeals. Key contact emails were provided for resolving specific billing issues.
Blue Cross Blue Shield of Wyoming · Identified Jun 19, 2026Medium impact
Reimbursement Update for COVID-19 Vaccine
Blue Cross Blue Shield of Wyoming updated COVID-19 vaccine billing codes and administration codes for Pfizer and Moderna vaccines. Each vaccine manufacturer has specific codes, with separate administration codes for first and second doses due to the two-dose requirement.
Premera Blue Cross · Identified Jun 18, 2026Medium impact
Medical Policy and Coding Updates - September 2019
Effective January 1, 2020, for individual plans only, subcutaneous implantable cardiac defibrillator code 33270, total ankle replacement codes 27702 and 27703, negative pressure wound therapy codes A6550, A7000 and E2402, and spinal orthosis codes such as L0450 and L0460 now require review for medical necessity and prior authorization, along with nerve block codes such as 64450 and 64490 and trigger point injection codes 20552 and 20553. Effective January 1, 2020, for individual plans only, many other codes including 92132, 77046 through 77049, 90460, 90461 and E0424 now require review for medical necessity. Effective September 1, 2019, hyoid myotomy code 21685 and denosumab code J0897 now require review for medical necessity and prior authorization, while lumbar discectomy codes 62287 and 62380 are reviewed for investigational status and no longer require prior authorization.

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REFERENCE DATA

Payers with rules2

Payers requiring prior auth2

CalViva Health · Effective December 31, 2025
Prior authorization required
CalViva Health CMS-0057-F prior authorization requirements
Community Health Plan of Imperial Valley · Effective December 31, 2025
Prior authorization required
Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does CalViva Health require prior authorization for 77063?

CalViva Health lists 77063 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 77063?

Community Health Plan of Imperial Valley lists 77063 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 77063?

There are 18 tracked policy changes affecting CPT 77063, including updates from Blue Cross Blue Shield of Vermont, Utah Medicaid, Humana. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 77063?

Payers that have issued tracked updates for CPT 77063 include: Blue Cross Blue Shield of Vermont, Utah Medicaid, Humana, BlueCross BlueShield of South Carolina, Colorado Medicaid, Florida Blue, Blue Cross & Blue Shield of Mississippi, Highmark, Aetna, NY Medicaid, Alaska Medicaid, Blue Cross Blue Shield of Wyoming, Premera Blue Cross.

How do I get notified when CPT 77063 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 77063. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 77063?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

See every payer rule for 77063

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 77063 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Preventive Care Reminder Sent to Members

July 2026 Medicaid Information Bulletin

Breast Imaging - Medicare Advantage (Revised)

2026 May Medical Policy Updates

2026 May Medical Policy Updates

Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600540 - 07/2026)

Breast Imaging - Medicare Advantage (Revised)

2026 May Medical Policy Updates

Accurate Documentation Optimizes Health Outcomes and More

Digital Breast Tomosynthesis

Breast Cancer Awareness Month: Tips for Rescheduling Patients before January

Mammography (CPB 0584, reviewed 2026-09-10)

Mammography (CPB 0584, reviewed 2025-09-09)

Breast Biopsy Procedures (CPB 0269, reviewed 2026-05-14)

New York State Medicaid Coverage of Breast Cancer Screening, Imaging, and Testing for Management and Treatment

July 2024 Town Hall FAQ

Reimbursement Update for COVID-19 Vaccine

Medical Policy and Coding Updates - September 2019

Prior authorization required

Prior authorization required

Does CalViva Health require prior authorization for 77063?

Does Community Health Plan of Imperial Valley require prior authorization for 77063?

What insurance policy changes affect CPT 77063?

Which payers have updated policy for CPT 77063?

How do I get notified when CPT 77063 policy changes?

Why do payers change policies for CPT 77063?