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Medical Policy Implementation: Digital Breast Tomosynthesis

Effective January 4, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for digital breast tomosynthesis services provided to members enrolled in coverage through large employer groups Inteplast Group, LTD. and Sanofi.

Based on the guidelines of our medical policy, Digital Breast Tomosynthesis, claims that include CPT® codes 77061, 77062, 77063 or HCPCS code G0279 for services provided on and after January 4, 2016 to members enrolled in coverage through Inteplast Group, LTD. and Sanofi will be denied as investigational/experimental services regardless of the submitted diagnosis.

ID cards of members enrolled through Inteplast Group, LTD. and Sanofi will include the group information noted below.

Inteplast Group, LTD. 
Group #: 75919 
Subgroup #s: 0000, 0001, 0002, 0003, 0004, 0005, 0006, 0007, 0008, 0009, 0010, 0011, 0012, 0013, 0014, 0015, 0016, 0017, 0018, 0019, 0020, 0021, 0022, 0023, 0024, 0025, 0026, 0027, 0028, 0029, 0030, 0031, 0032, 0033, 0050

Sanofi
Group #: 76089 
Subgroup #s: 0000, 0001, 0002, 0003, 0004, 0005, 0010, 0011, 0012, 0013, 0014, 0020, 0021, 0022, 0023, 0024, 0025, 0026, 0030, 0031, 0032, 0033

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after January 4, 2016.

CPT® is a registered mark of the American Medical Association.

Published on: October 2, 2015, 12:24 p.m. ET
Last updated on: November 24, 2020, 23:45 p.m. ET