An official State of Texas website.
Revision 24-2; Effective Sept. 20, 2024
Guidelines for Determination of Qualifying Diagnosis
Texas Breast and Cervical Cancer Services (BCCS) provides the following guidance to health care providers and grantees to facilitate their determination of qualifying diagnoses for Medicaid for Breast and Cervical Cancer (MBCC). Analysis of all biopsies must be performed by a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory.
Cervical Cancer Qualifying Diagnoses
Qualifying precancerous cervical diagnoses must be biopsy-confirmed*:
- High-grade dysplasia or cervical intraepithelial neoplasia (CIN 2/3 or CIN 3)
- Carcinoma or adenocarcinoma in situ
Qualifying malignancies of the cervix must be biopsy-confirmed*:
- Adenocarcinoma
- Adenoid cystic carcinoma
- Adenosquamous carcinoma
- Glassy cell carcinoma
- Invasive cervical cancer
- Invasive endocervical adenocarcinoma
- Invasive neoplasm
- Malignant neoplasia
- Melanoma
- Sarcoma
- Small cell carcinoma
- Squamous cell carcinoma
* Cervical biopsy or endocervical sampling that have a qualifying pre- cancerous diagnosis or cervical malignancy qualify as biopsy confirmed.
Breast Cancer Qualifying Diagnoses
Qualifying breast cancer diagnoses must be biopsy-confirmed. On the pathology report, the diagnosis or the description of the specimen, or both, may include at least one of the following phrases: breast cancer, breast carcinoma or breast malignancy.
Examples of the majority of breast cancer types are:
Ductal Carcinomas
- Comedo
- Cribriform
- Ductal carcinoma in situ (DCIS)
- Infiltrating
- Inflammatory
- Invasive
- Medullary
- Mucinous (colloid)
- Papillary or Micropapillary
- Scirrhous
- Tubular
Lobular Carcinoma*
- Invasive
- Infiltrating
Nipple Carcinoma
- Paget’s disease
Other Carcinomas
- Adenoid cystic carcinoma
- All Phyllodes tumors
- Any biopsy-proven malignancy identified in a biopsy of either breast
- Apocrine
- Carcinoma, NOS (not otherwise specified)
- Carcinoma with endocrine differentiation
- Metaplastic
- Primary lymphoma
- Sarcoma
- Secretory
- Undifferentiated carcinoma
* A diagnosis of lobular carcinoma in situ (LCIS) is not considered a qualifying pre-cancerous or breast cancer diagnosis for referral to MBCC.
For a medical condition to qualify as a breast cancer, the medical record documentation, such as the operative report or procedure note, must state that a biopsy was taken from at least one breast and a pathology report for that biopsy must confirm the diagnosis of a qualifying malignant lesion. The pathology report does not need to describe the malignancy as definitively representing a breast primary. A malignancy identified on at least one biopsy of the breast must be clear from the medical record documentation.
Metastatic Breast and Cervical Cancers
For clients who present with cancers believed to be metastatic from the breast or cervix, if a diagnosis is made based only on the metastatic tumor, a Medicaid application may be considered if:
- no further diagnostic workup is planned before treatment is initiated; and
- treatment will proceed on the assumption that the primary source is breast or cervix, regardless that a primary tumor has not been identified.
The medical record documentation must clearly state that the primary source is believed to be breast or cervix and that treatment will be initiated based on that assumption. Terms such as compatible with and consistent with a breast or cervical cancer are acceptable. For example, a diagnosis such as metastatic adenocarcinoma consistent with a breast primary would be acceptable.
For clients who present with cancers metastatic to the breast or cervix, malignancy diagnosed in a biopsy taken from a breast or from the cervix constitutes a qualifying diagnosis.