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http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. , SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 2 The HPV vaccine (Gardasil) is covered to age 45 per the Food and Drug Administration (FDA) guidelines. Check out the changes and updates to our plan in 2023. Here's how to interpret your BMI: Below 18.5: underweight. MRI of the breast may be considered medically necessary for individuals with silicone implants whenEITHERof the following are met: MRI of the breast may be considered medically necessary for individuals with no history of known breast cancer, MRI of the breast may be considered medically necessary for individuals with history of known breast cancer. As we see trends evolve that may impact patient safety, quality of care or affordability, we must implement solutions that protect our members from these trends. The site may also contain non-Medicare related information. Some buy into dangerous myths about breast cancer. Annual physical exams and other preventive services are free when you use a Preferred provider. Tissue doesnt overlap. Does this prior approval impact Blue Medicare HMO and Blue Medicare PPO? See your doctor andrefer to the CDCs posted schedule of immunizations for more information. Call the National Information Center at 1-800-411-BLUE (2583) weekdays from 8 a.m. to 8 p.m. Eastern time. BCBSIL Provider Manual June 2020 2 . You should get screenings every one or two years, depending on your doctor's advice. Blue Cross NC has partnered with American Imaging Management, Inc. (AIM) for the management of outpatient, high-tech diagnostic imaging services. American Imaging Management (AIM) was selected as a vendor in part due to their track record of creating cost savings while reducing the unnecessary administrative burden on physician offices. The good news is that mammograms can catch cancer early, when its easiest to treat, even if you dont have any symptoms. Preventive care includes routine well exams, screenings and immunization intended to prevent or avoid illness or other health problems. TheU.S. Preventive Services Task Forcerecommends that women between the ages of 50 and 74 get a mammogram every two years. No. Here's a deeper dive on the potential benefits and risks of a 3D mammogram. Evaluation of suspected breast cancer when other imaging examinations, such as ultrasound and mammography, and physical examination are inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g. Some women have a higher risk of developing cancer than other women. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association . All Rights Reserved. To learn if your patient's plan requires prior approval for these services, please reference the diagnostic imaging procedures page. Who reviews requests for diagnostic imaging prior approval? Coverage is subject to the specific terms of the member's benefit plan. It may also be used to depict residual disease after neoadjuvant chemotherapy. Women ages 40 and older can receive a mammogram (four views) each calendar year. The goal of the diagnostic imaging program is to improve affordability of health care to Blue Cross NC members. Regular mammograms improve survival rates by 35% in women over 50. Assessing Your Risk We use cookies on this website to give you the best experience and measure website usage. For more information, view our privacy policy. HMO coverage is offered by Health Options, Inc. DBA Florida Blue HMO. This is especially important for women who have dense breast tissue. Mental Health Services. Cost estimates are based only on the coverage you have with us. Women ages 35-39 can receive one baseline mammogram(four views). $300 inpatient benefits. Echocardiography studies (effective for both Commercial and Blue Medicare HMO\PPO lines of business as of January 2, 2014), Member identification number, name, date of birth, and health plan, Imaging exam(s) being requested (body part, right, left or bilateral), Patient diagnosis (suspected or confirmed), Clinical symptoms/indications (intensity/duration), Results of treatment history (previous tests, duration of previous therapy, relevant clinical medical history), American Institute of Ultrasound in Medicine (AIUM), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) and National Coverage Determinations (NCD), Promoting and guiding the selection of the most appropriate and cost-effective diagnostic imaging services, Encouraging standardization of medical practice patterns and reducing variation in clinical evaluation, Curtailing the performance of inappropriate diagnostic imaging studies, Advocating biosafety issues, including reduction of clinical radiation exposure (for CT and plain film radiography), Enhancing quality of health care for diagnostic imaging studies using evidence-based medicine and outcomes research from numerous resources. Pays in addition to your other coverages. Breast cancer is the most widely found cancer in U.S. women, next to skin cancer. Easy: Keeping up with your screenings is an important task, even in your busy life. Service & Support; FAQs; Find an Event; Public Service Recognition; About Us; 1 results found for search term : mammograms. A Pap test and high-risk human papillomavirus (hrHPV) test every 5 years or. Learn more about our non-discrimination policy and no-cost services available to you. Blue Cross Blue Shield Global Core gives Blue Cross and Blue Shield of Vermont members access to their health care benefits wherever they go - across the country and around the world. This allows the whole breast to be seen. Women ages 40 and older can receive a mammogram (four views) each calendar year. These benefits are currently in effect unless otherwise noted. It's important to note that your provider has the right to code and bill services according to his or her viewpoint. Servicing providers (hospitals, freestanding imaging centers, etc.) Medications covered at 100%: Lovastatin (20 or 40 mg) or Pravastatin (10, 20, 40 or 80 mg). should confirm that a prior approval number has been issued. Regence supports women's preventive breast health. What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. Regular mammograms improve survival rates by, Thanks in part to preventive screenings, there are approximately, The average mammogram appointment is just. 1 If you have gotten one dose of Zostavax vaccine for shingles, you should also get the two doses of Shingrix vaccine. Blue Cross and Blue Shield Association . Colorectal Cancer . 25 - 29.9: overweight. Mammograms are one of the best ways to find it early. seen only in single view mammogram without ultrasound correlation); Previous positive breast biopsy within the previous four (4) months and no intervening previous breast MRI; Evaluation of palpable lesion on physical examination and not visualized on ultrasound or mammogram and MRI guided biopsy considered; For evaluation of axillary node metastasis or adenocarcinoma with normal physical examination and normal breast mammogram; Individuals diagnosed with biopsy-proven lobular neoplasia or atypical ductal hyperplasia (ADH); Personal history of or first-degree relative with Le-Fraumeni syndrome (TP53 mutation), Cowden syndrome (PTEN) or Bannayan-RileyRuvalcaba syndrome (BRRS). Coverage Information. Under the benefits of certain plans, the following diagnostic imaging services that are received in an outpatient setting, such as in a medical office, the outpatient department of a hospital or at a freestanding imaging center may require prior approval (for dates of service on or after February 15, 2007 for Blue Cross NC commercial plans and September 1, 2010 for Blue Medicare HMO and Blue . Barium enema is a covered service but not at 100% so you may have out of pocket costs. You are leaving this website/app ("site"). Learn more about our other insurance plans and Medicare plans, or contact a sales . If you get benefits from your employer, you may also have these benefits. Annual physical exams and other preventive services are free when you use a Preferred . Understand the difference between preventive and diagnostic. 2023 Blue Cross and Blue Shield of North Carolina. Coverage is subject to the specific terms of the member's benefit plan. Cat-scan technology exposes patients to more radiation than an X-rays. Scenario 1: Brand Truvada, Viread, or Descovy may be made available if you are clinically unable to use generic Truvada. Click on a service to see any limits or exclusions. Starting June 1, 2022, this follow up colonoscopy will be covered at 100%. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. 122 0 obj <>/Filter/FlateDecode/ID[<13345823F9F84C49978F51E9E4B0DEB3><85AA0C7815CFFF46BE97C496C3A4895B>]/Index[104 37]/Info 103 0 R/Length 89/Prev 75360/Root 105 0 R/Size 141/Type/XRef/W[1 2 1]>>stream Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. To view this file, you may need to install a PDF reader program. Its important for adult women to have annual wellness exams after the age of 21. A high BMI can be a warning sign for potential health problems. The program will apply to members covered by the following plans: Blue Options SM (group PPO plan), Blue Option HRA (group PPO plan), Blue Options HSA (group and individual PPO plan), Classic Blue (Group CMM plan), Dental Blue (group and individual dental plan), Blue Advantage (individual PPO), Short Term Health Care (individual CMM plan). The diagnostic imaging management program guidelines are based on the most up-to-date recommendations of physician organizations such as the American College of Radiology and the American College of Cardiology. Blue Shield of California 1999 . Ordering physicians may also contact the AIM physician reviewer at any time during the authorization process. Your browser is not supported. You usually need to get tested every 3 to 5 years. Necesita su ID de usuario? Scroll down to see some common services that may or may not be covered during a preventive care visit. Breast Cancer. Breast MRI should be bilateral except for those with a history of mastectomy or when the MRI is being performed expressly to further evaluate or follow findings in one (1) breast. Mammograms are one of the best ways to find it early. For that reason, benefits for preventive BRCA testing are available for members with a family history of certain cancers. Blue Cross NC is the fourth insurer in the state to implement a diagnostic imaging management program, and we understand that our physician community has vital feedback that will help make our program successful. 140 0 obj <>stream File is in portable document format (PDF). Health plans are offered by Blue Shield of California. Find A Doctor Or Hospital In Your Network. The American Cancer Society recommends women ages 40 to 54 get annual mammograms, and women 55 and older get screenings every two years. Place of service exclusion: Sterilization coverage applies to all places of service, with the exception of the Emergency Room. You are only exposed to a small amount of radiation during a mammogram, and studies show that the benefits of mammograms outweigh any risks. BlueCross BlueShield of South Carolina. HMO Scope of Benefits Section . %%EOF By Regence. There are also additional guidelines if you're pregnant. There is an appeals process in place for unfavorable determinations. 18.5 - 24.9: healthy weight. "Screening" means checking a woman's breasts for cancer before there are signs or symptoms of the disease present. What you need to know about the disease and our commitment to ensuring you have access to the right care at the right time. The diagnostic imaging management program impact is low; why did Blue Cross NC implement it? Mammograms arent as painful as you think you may feel a little pressure but it only lasts a few seconds. This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. After your annual preventive exam, you will receive an Explanation of Benefits (EOB) from Blue Shield of California to notify you that your claim has been processed. Under the Affordable Care Act (ACA), CareFirst and other health insurance carriers must cover a set of preventive serviceslike shots and screening testsand no cost to you. Routine mammograms are covered by the state health plan at no cost to you. Your member ID card is your key to using your medical plan benefits. Women between the ages of 40 and 49 should talk to their doctor about when they should start getting mammograms. Recommended repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 2428 weeks gestation unless the biological father is known to be Rh (D)-negative, Anesthesia services will pay at 100% only for sterilization, Certain services for contraceptive device insertion and removal, such as ultrasounds to confirm IUD placement, will pay at 100%, Pregnancy tests prior to the initiation of contraceptive will pay at 100%. Most PDF readers are a free download. Select a Region: Please Select One DVEST1 DV9ST1 DV8ST1 DV5ST1 DV4ST1 DV1ST1 DVPST1 DVOST1 DVMST1 DVJST1 DVHST1 DVGST1 DVFST1 DVEST1 DVDST1 DVCST1 LOEST1 But Humana, which I have now, is even worse because I have a $50 copay just for screening." 3. Hospitals and freestanding imaging centers that perform the imaging services cannot obtain the approval. To capture them, the breast is pulled away from the body, compressed and held between two glass plates. Plus, your medical plan covers 100% of the costs for preventive health services when care is provided through network providers. Forgot Password? If you have questions about coverage for preventive services, . Reimbursement Guidelines - Alphabetical Index, Reimbursement Guidelines - Categorical Index, Become a Blue Cross NC Provider or Recredential, Contact Information for Regional Network Management, Responsibilities of Primary Care Physicians (PCP) in 2008, IPP Coordination of Benefits Questionnaire. Currently, under the Patient Protection and Affordable Care Act Annual Checkups and certain preventive . If your Summary of Benefits section of your Benefit Booklet contains PREVENTIVE CARE covered under federal law, then you have these benefits at no charge IN-NETWORK. List of all medications that are covered at 100% onall formularies. Accessibility However, sometimes tests are ordered and are not clinically appropriate. Blue Cross and Blue Shield Service Benefit Plan brochures, https://www.mayoclinic.org/tests-procedures/brca-gene-test/about/pac-20384815. Mammograms are the best way to screen for breast cancer and can detect cancer up to three years before other signs and symptoms appear. Limited to a 90 day supply each for two cessation efforts. By slowing this growth and containing costs through a proactive diagnostic imaging management program, we anticipate costs savings over time. Best Answer. Salpingectomy for sterilization purposes will be covered as preventive effective 7.1.22, Trans-dermal contraceptives (i.e., contraceptive patches), Diaphragms are available only through the pharmacy and IUDs are available only through a professional provider, If there is a medical reason you cannot take a generic contraceptive, your doctor should review this, Diaphragms, vaginal rings, contraceptive patches, female condoms, sponges, spermicides, and emergency contraception are available only with a prescription. While radiation exposure can cause cancer, new technology helps reduce the amount of radiation exposure that comes with a mammogram. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. Preventive Care. There are many easy-to-use BMI calculators online, such as this example from the Centers for Disease Control and Prevention.*. Tests that do not meet national clinical guidelines will not be approved. listed below will be covered by your plan. "Breast cancer is the most common cancer in American women, but men can also develop breast cancer," said Blue Cross and Blue Shield of . In addition, some sites may require you to agree to their terms of use and privacy policy. The remaining 40% are out-of-pocket costs. Anesthesia and pathology from polyps found during a screening colonoscopy is covered at 100%. No lump, no cancer. The following preventive services and immunizations do not apply to all health plans administered or insured by Blue Cross and Blue Shield of Alabama. You have coverage from another insurance plan in addition to your Blue Cross and Blue Shield of Nebraska coverage. Screenings, tests and other preventive care services Preventive care service Cost . Most breast cancers are found in women 50 years old and older. Since their introduction, standard mammograms also called screening mammograms have helped save countless lives. This document provides you with information about how your claim was paid, including your payment responsibility or reimbursement, if any. Your doctor will help you decide what schedule makes the most sense for you. Take advantage of preventive care and stop problems before they get serious. Negotiated rates with providers can change, therefore, changing the estimate. 0 For example, at the Kapiolani Medical Center [ 1] in Aiea, Hawaii, where the full . Prior approval also is not required for "low-tech" procedures such as X-rays, ultrasounds and mammograms. For most women, mammogram technology is still considered the best way to detect breast abnormalities and cancers early. What information is required to request prior approval? Diagnostic care includes care or treatment when you have symptoms or risk factors and your doctor wants to diagnose them. Your coverage information in the palm of your hand. Call us at 1-888-243-4420 if you have questions or need help. To be covered with no out-of-pocket costs, the service must be: Special information for employees of religious organizations. Discover all the ways members can earn wellness incentives and rewards for taking an active role in their health. One option is Adobe Reader which has a built-in reader. Additionally, we cover computer-assisted detection for those women who seek an extra level of screening for breast cancer. Yes, as of September 1, 2010, all Blue Medicare HMO and Blue Medicare PPO members participate in the program. NRT through QuitlineNC is available without a prescription. The policies were effective September 1, 2010 for Blue Medicare HMO and Blue Medicare PPO plans. Fraud and Abuse Issuance of a prior approval number is not a guarantee of payment. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Learn more about our non-discrimination policy and no-cost services available to you. Inconclusive screening mammogram due to breast characteristics limiting the sensitivity of mammography (e.g., extremely or heterogeneously dense breasts, implants); A breast cancer risk assessment (by the Gail risk or other validated breast cancer risk assessment models) that identifies the individual as having a lifetime risk of 20% or greater of developing breast cancer (approve annually); Two (2) or more first degree relatives (parents, siblings, and children) have history of breast cancer; Individuals with histories of extensive chest irradiation (usually as treatment for Hodgkin's or other lymphoma.) Please review the terms of use and privacy policies of the new site you will be visiting. For screening examination to detect breast cancer in. Since these are preventive care visits, there is no cost when seeing a Preferred provider for both Basic and Standard Option members. Connect Community - Blue Cross and Blue Shield of Illinois, Radiation treatments to the breast or chest area. Technical Information $X^ "@\(k'h,@7HI?NH2012|Igl ` |> Blue Cross and Blue Shield Association. Learn more aboutmammogram screeningsin this video. Find an in-network doctor for preventive care. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Privacy Policy They are regularly reviewed by physicians of appropriate specialties for consistency with the most recent medical evidence. Its common to receive a Pap test (also called a Pap smear or pelvic exam) during your visit. FDA-approved tobacco cessation prescription. Internal Medical Policy Committee 11-19-2020 Annual Review-Title changed slightly, Internal Medical Policy Committee 11-23-2021 Annual Review-no changes in criteria, Internal Medical Policy Committee 11-29-2022 Annual Review-no changes in criteria. Research shows 3D mammography (breast tomosynthesis) can detect breast cancer 28% more accurately than standard mammograms.