Mammography — CPB 0584 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0584 — its mammography coverage policy — effective September 26, 2025. Here's what billing teams need to do before claims start hitting the new criteria.

This update to CPB 0584 Aetna's mammography policy touches CPT codes 77061, 77062, 77063, 77065, 77066, 77067, and HCPCS code G0279. The policy covers screening and diagnostic mammography across a broader population than many billing teams realize — including BRCA-positive men, transfeminine patients, and younger women with specific hereditary syndromes. If your charge capture isn't built around these criteria, you're either leaving reimbursement on the table or heading toward a claim denial.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Mammography — CPB 0584
Policy Code	CPB 0584
Change Type	Modified
Effective Date	September 26, 2025
Impact Level	High
Specialties Affected	Radiology, OB/GYN, Breast Surgery, Oncology, Primary Care
Key Action	Audit your charge capture for CPT 77061–77067 and G0279 against the updated medical necessity criteria before billing claims with a September 26, 2025 or later date of service

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Aetna Mammography Coverage Criteria and Medical Necessity Requirements 2025

The Aetna mammography coverage policy under CPB 0584 is organized around who qualifies for screening versus diagnostic services. Knowing the difference matters, because diagnostic mammography (CPT 77065 and 77066) carries different documentation requirements than screening.

Standard Screening — Women 40 and Older

Annual screening mammography, billed with CPT 77067, is considered medically necessary for all women aged 40 and older. No additional diagnosis codes or documentation of elevated risk are required at the standard threshold.

High-Risk Screening — Women Under 40

Younger women qualify for annual screening under five specific conditions. Aetna covers screening mammography for patients who are:

For these patients, document the qualifying condition explicitly. Use the appropriate ICD-10-CM code from the hereditary neoplasm or personal history code ranges — Aetna's coverage policy is clear that the diagnosis or history must support the claim.

BRCA-Positive Men

This is where a lot of billing teams miss claims. Aetna considers annual screening mammography medically necessary for BRCA-positive men with gynecomastia. Coverage starts at age 50, or 10 years before the earliest known male breast cancer in the family — whichever comes first.

If your practice sees male breast patients, make sure your charge capture handles this population. Billing 77067 on a male patient will raise a flag without the right diagnosis coding and documentation to support it.

Transfeminine Patients

Aetna covers screening mammography for transfeminine (male-to-female) persons who are 40 or older and have used hormones for five or more years. This is a population that generates frequent prior authorization questions. The policy is clear: medical necessity is met when both the age and the duration of hormone use are documented.

If your practice serves this population and you're not capturing hormone use duration in your documentation workflow, fix that now. A claim denial on this basis is avoidable.

Diagnostic Mammography

CPT 77065 (unilateral) and 77066 (bilateral) cover diagnostic mammography for any member — women or men — with signs or symptoms of breast disease, or a history of breast cancer. Aetna explicitly states that diagnostic mammography is covered regardless of whether the member has preventive services benefits.

That last sentence matters. Don't assume a patient's plan exclusions for preventive services block diagnostic mammography billing. They don't, under this coverage policy.

3D Mammography and CAD

Aetna considers digital breast tomosynthesis (CPT 77061, 77062, 77063, and HCPCS G0279) an acceptable alternative to standard 2D mammography. Computer-aided detection (CAD) is considered a medically necessary adjunct — meaning you don't need a separate justification to bill it alongside the primary mammography code. The CAD component is already bundled into CPT 77065, 77066, and 77067 per the code descriptors.

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Coverage Indications at a Glance

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Aetna Mammography Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. If you haven't already audited your workflows against this updated policy, do it now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Mammography Under CPB 0584

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
G0279	HCPCS	Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066)

Key ICD-10-CM Diagnosis Codes

The full ICD-10-CM code list under CPB 0584 contains 122 codes spanning malignant breast neoplasms, carcinoma in situ, and related diagnoses. Pull the complete list from the source policy before updating your charge capture — partial ICD-10 mapping is one of the most common causes of unnecessary claim denial on mammography claims.

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