CMS Pub. 100-03, ch. 1, § 220.4

CIM 50-21

A diagnostic mammography is a radiologic procedure furnished to a man or woman with signs and

symptoms of breast disease, or a 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. A diagnostic

mammography is a covered service if it is ordered by a doctor of medicine or osteopathy as defined in §1861

(r) (1) of the Act. A screening mammography is a radiologic procedure furnished to a woman without signs

or symptoms of breast disease, for the purpose of early detection of breast cancer, and includes a physician’s

interpretation of the results of the procedure. A screening mammography has limitations as it must be, at a

minimum a two-view exposure (cranio-caudal and a medial lateral oblique view) of each breast. Payment

may not be made for a screening mammography performed on a woman under age 35. Payment may be

made for only one screening mammography performed on a woman over age 34, but under age 40. For an

asymptomatic woman over age 39, payment may be made for a screening mammography performed after at

least 11 months have passed following the month in which the last screening mammography was performed.

A radiological mammogram is a covered diagnostic test under the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated;

• A patient has a history of breast cancer; or

• A patient is asymptomatic but, on the basis of the patient’s history and other factors the physician

considers significant, the physician’s judgment is that a mammogram is appropriate.

Use of mammograms in routine screening of: (1) asymptomatic women aged 50 and over, and (2)

asymptomatic women aged 40 or over whose mothers or sisters have had the disease, is considered

medically appropriate, but would not be covered for Medicare purposes.

Cross-reference:

The Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §80.

The Medicare Benefit Policy Manual, Chapter 1, “Inpatient Hospital Services,” §50