Wiki Screening Mammos for Men?

[mdudley21]

I have a claim for a screening mammo with tomo that is being denied due to invalid gender. The patient is a man with a personal history of breast cancer and has a Medicare Advantage plan. I called the insurance company and they told me to try to submit an appeal with his medical records, but I was wondering if anyone else has ran into this.

I combed through the codes' LCD article to see if they're only covered for women. It never says anything about them being for a specific gender and the entire body of the article text and guidance is written gender neutrally.

Would this be avoided if his PCP ordered a diagnostic mammo with tomo instead of screening? I frequently run into issues with women being too young to have the screening covered and having to just write off the charges, but then next patient will be same age getting a diagnostic and insurance pays it no problem.

 

[csperoni]

Not my area of specialty, but since no one else chimed in, I will provide my input.
1) Yes, I would think a patient with a personal history of breast cancer (male or female) would be a diagnostic mammo, not a screening mammo
2) You may want to investigate -KX modifier if the reason for denial is gender related. I need to use this occasionally on claims for transgender patients where the procedure and/or diagnosis is causing a gender related denial.
Hope that helps and perhaps someone with expertise in this area could provide additional input.