Pennsylvania Statutes Title 40 P.S. Insurance § 764c.1. Coverage for mammographic examinations, magnetic resonance imaging and other forms of breast imaging

(1) Mammographic examinations as follows:

(2) Supplemental breast screenings for a covered person whose risk level for breast cancer is determined to be at least average risk or higher.

(3) Diagnostic breast examinations for a covered person whose risk level for breast cancer is determined to be at least average risk or higher.

(1) Article XXI.  1

(2) The terms and conditions of the health insurance policy, provided such terms and conditions are consistent with this section.

(3) Applicable Federal law and regulations.

(1) Preclude an insurer from applying utilization review under Article XXI.

(2) Prevent the application of deductible, copayment or coinsurance provisions for breast imaging services beyond the minimum coverage required under subsection (a).

(3) Require an insurer to cover a surgical procedure known as mastectomy.

(1) Except as provided under paragraph (2), the terms in this section shall have the same meanings as provided in section 2102.

(2) As used in this section, the following words and phrases shall have the meanings given to them in this paragraph unless the context clearly indicates otherwise:

“Average risk” means a covered person who meets all of the following criteria:

(i) Has, based on clinical review criteria, a 15% or less lifetime risk of being diagnosed with breast cancer during the covered person's lifetime.

(ii) Has no personal history of breast cancer.

(iii) Has no family history of breast cancer.

(iv) Has no known BRCA gene mutation.

(v) Has no history of radiation therapy before 30 years of age.

(vi) Has no personal history of atypical breast histologies.

(vii) Has not undergone prior therapeutic thoracic radiation therapy.

(viii) Does not have heterogeneously dense or extremely dense breast tissue.

(ix) Does not have a personal history of Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or a first-degree relative with one of these syndromes.

“Diagnostic breast examination” means a medically necessary and clinically appropriate examination of the breast using diagnostic mammography, standard or abbreviated breast magnetic resonance imaging or breast ultrasound when an abnormality is seen or suspected.

“Supplemental breast screening” means a medically necessary and clinically appropriate examination of the breast using either standard or abbreviated magnetic resonance imaging or, if such imaging is not possible, ultrasound, if recommended by the treating physician, to screen for breast cancer when no abnormality is seen or suspected.