Revised: Update to Screening Mammography Reimbursement Restrictions

An article published in the February 2016 Medi-Cal Update announced that, effective for dates of service on or after March 1, 2016, reimbursement for screening mammograms is restricted to females 50 to 74 years of age. This announcement was not compliant with the Consolidated Appropriations Act of 2016 (House Resolution 2029). Providers should continue to provide mammography services. Breast cancer screening mammography for females 40 years of age and older every one to two years is reimbursable. This change will be made effective in a future Medi-Cal Update. There are no diagnostic restrictions for screening mammograms. An approved Treatment Authorization Request (TAR)may override gender and age restrictions. Providers should continue to submit claims timely. If applicable, affected claims for recipients 40 to 50 years of age will be processed separately, which may delay reimbursement.