CommercialCoverageHigh impact
Mammography (CPB 0584, reviewed 2025-09-09)
Aetna·Radiology, Oncology, OB-GYN +3 more·Medical Policy
Effective date
Sep 9, 2025
We identified it
Aug 18, 2026
Summary
Aetna has updated its mammography coverage policy (CPB 0584, effective 2025-09-09) to clarify covered and non-covered indications, including expanded coverage for transfeminine persons (40+ with 5+ years hormone use) and BRCA-positive men with gynecomastia. The policy explicitly classifies AI-based mammography, contrast-enhanced mammography (CEM), and low-dose CT combined mammography as experimental/investigational and not covered. Billing teams must ensure claims align with the specific medical necessity criteria outlined.
Action Required
By September 9, 2025, billing team must: (1) Update billing system to enforce coverage criteria - require documentation of patient age (40+), BRCA status, high-risk syndrome diagnosis, radiation history, gender identity/hormone use duration, or breast disease symptoms/history before approving claims for CPT 77061, 77062, 77063, 77065, 77066, 77067, and G0279; (2) Configure system to DENY claims for CPT codes without documented medical necessity matching approved indications; (3) Create hard stops in billing software to REJECT any claims attempting to bill AI-based mammography, contrast-enhanced mammography (CEM), or low-dose CT combined mammography - these are non-covered/experimental; (4) Providers and front desk staff must add screening questions to intake forms to document: patient age, BRCA/genetic mutation status, family history of breast cancer, personal cancer history, prior chest radiation (ages 10-30), and for transfeminine patients, hormone use duration; (5) Update denial appeal templates to reference Section II experimental indications. Failure to implement will result in claim denials and member billing exposure for non-compliant claims.