What constitutes a high risk of breast cancer?

[wondercheka]

I'm currently working some claims where women younger than 35-years-old have had screening mammograms. As is typical, practically zero payers will reimburse these. However, I've got one payer that states the following in their mammography policy: "Coverage No payment will be made for a screening mammogram provided to a member under 35 years, unless a woman is at a high risk of developing breast cancer and medical necessity is provided. The patient's medical record must clearly document the patient's immediate risk of developing breast cancer at an age less than thirty-five."

So what, exactly, would constitute an immediate risk of developing breast cancer? A lot of the claims I've seen state the patient has a family history of breast cancer, but it tends to be in the extended family (grandmothers, aunts, and cousins) rather than the immediate family (mother, sister, or daughter). The other thing I'm finding is when I review the office visit records, the family history isn't even documented, which gives me even less to try to appeal on.

 

[blondie525]

There was an article years ago that stated it had to be a first degree relative (mother, sister, daughter) I don't remember where it was published though.