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

IMMEDIATELY: Billing team must update authorization and denial logic in billing system to reflect new covered populations: (1) Annual screening mammography for transfeminine persons aged 40+ with 5+ years hormone use history—add gender identity disorder ICD-10 codes F64.8-F64.9 to coverage criteria in system; (2) Annual screening for BRCA-positive men starting at age 50 or 10 years before earliest family male breast cancer history; (3) Clarify that diagnostic mammography (CPT 77065, 77066) is covered regardless of preventive benefits status. Update EMR/billing templates to capture hormone use duration (5+ years requirement) for transfeminine patients and family history triggers for male patients. STOP BILLING as investigational: AI-based mammography (deep learning/machine learning), contrast-enhanced mammography for non-high-risk patients, and low-dose CT combined mammography for nipple discharge (N64.52)—these codes should trigger automatic denials with education to providers. Implement system rule: CEM (contrast-enhanced mammography) is covered ONLY for high-risk patients meeting MRI criteria but with documented MRI contraindications (incompatible device, claustrophobia, contrast allergy, access barriers)—add documentation requirement fields. Providers and billing staff should receive training on new gender-affirming care coverage language and high-risk male breast cancer screening criteria. Update precertification workflow to verify transfeminine patients' hormone use duration before authorizing CPT 77067 (screening mammography bilateral). Failure to implement these changes will result in claim denials for out-of-criteria services and potential member appeals for denied claims on new covered populations.