One screening mammogram every 12 months* is covered for women with average risk beginning at age 40. Women with a high risk of breast cancer may receive a screening mammogram beginning at age 30. High-risk indicators include:
- a lifetime risk of breast cancer of 15 percent or greater using standard risk assessment models such as: Gail model, Claus model or Tyrer-Cuzick
- history of breast cancer
- known BRCA1 and BRCA2 gene mutation
- a parent, child or sibling with a BRCA1 or BRCA2 gene mutation and the beneficiary has not had genetic testing for this mutation
- radiation therapy to the chest between 10 and 30 years of age
- history of LiFraumeni, Cowden or Bannayan-Riley-Ruvalcaba syndrome, or a parent, child or sibling with a history of one of these syndromes
Active duty services members require an approval from HNFS. TRICARE Prime (when seeing a network provider) and TRICARE Select beneficiaries do not require an approval from HNFS.
Screenings include a 2D mammogram or 3D mammogram (also known as a digital breast tomosynthesis).
*A grace period allows a mammogram 30 days prior to the anniversary date of the last exam.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.
Diagnostic (non-routine) mammography, including 3D renderings, to further define breast abnormalities or other problems is a covered benefit. Use our Ancillary Services Approval Requirements tool to determine if the type of diagnostic screening requires an approval from HNFS.