Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

BR-1: Breast Ultrasound

BR-1: Breast Ultrasound

This General Policy section provides an overview of the basic criteria for which breast imaging may be medically necessary. Details regarding specific conditions or clinical presentations and the associated criteria for which imaging is medically necessary are described in subsequent sections.

For this condition imaging is medically necessary based on the following criteria:

† Routine performance of breast ultrasound as stand-alone screening or with screening mammography is inappropriate.^1,2,3

® Ultrasound screening for women whose only indication is dense breast tissue is not indicated.^1,2,3
® Equivocal or Occult Findings:
¡ Radiologist Report recommendation for Breast ultrasound (CPT^® 76641 or CPT^® 76642) and inconclusive or conflicting findings on mammography or MRI Breast

® A clinical office visit is not necessary prior to breast ultrasound when an abnormality has been identified on recent (within the last 60 days) mammogram.

® If repeat imaging remains BI-RADS™ 3, repeat at 12 months, 18 months, and 24 months from the date of the initial imaging. After 2 years of stability, the finding should be assessed as benign (Cat 2).¹⁶
® If repeat imaging is BI-RADS™ 1 or 2, then imaging reverts to routine per individuals risk profile.

† Axilla ultrasound (CPT^® 76882)

® For women with clinically suspicious lymph nodes, preoperative axillary ultrasound with a FNA or biopsy can help identify members who have positive nodes.³
¡ See Adult Chest Imaging Policy (Policy #150 in the Radiology Section); CH-2.2: Axillary Lymphadenopathy
® Bilateral should be coded CPT^® 76882 x 2

® Additional lesions should be billed using CPT^® 19084.

† State Specific Density Reporting and Imaging Mandate Laws

® Breast density notification laws have been put into effect by many states. Breast density notification laws vary, but some also contain mandates for additional imaging, which may include MRI and/or ultrasound. For applicable requests involving members in these states, their legislative mandates should be followed. The pertinent language in these mandates is provided via the link below.

BR-2: Breast MRI

BR-2: Breast MRI

For this condition imaging is medically necessary based on the following criteria:

† The use of gadolinium contrast is required for the evaluation of breast parenchyma.

† The use of gadolinium contrast is not necessary for the evaluation of implant integrity in asymptomatic, average-risk members.

† Computer-aided detection (CAD) is included with the MRI Breast CPT^® 77049 and CPT^® 77048 procedures. The use of HCPCS code C8937 (CAD including computer algorithm analysis of MRI Breast data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation) is unnecessary with these procedures.

® The use of CAD has little influence on the sensitivity and specificity of MRI Breast interpretation.⁹
® The use of HCPCS code C8937 (CAD including computer algorithm analysis of MRI Breast data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation) is currently considered investigational.
® Since the CAD software automatically performs 3D imaging, CPT^® 76376 or CPT^® 76377 should not be used in conjunction with CPT^® 77049, CPT^® 77048 or HCPCS code C8937

† Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral (CPT^® 77048) may be preferred in some individuals after mastectomy, per physician request.

† Magnetic resonance imaging, breast, without contrast material; bilateral (CPT^® 77047) or Magnetic resonance imaging, breast, without contrast material; unilateral (CPT^® 77046) may be performed if there are clinical reasons or concerns regarding the use of gadolinium contrast.

† MRI guided breast biopsy (CPT^® 19085) includes the imaging component.

® Additional lesions should be billed using CPT^® 19086.

MRI Breast – Practice Notes

† Although MRI Breast has superior sensitivity in identifying new unknown malignancies, it carries a significant false positive risk when compared to mammogram and ultrasound. Incidental lesions are seen on 15% of MRI Breast and increase with younger age. The percentage of incidental lesions that turn out to be malignant varies from 3% to 20% depending on the member population. Cancer is identified by MRI Breast in only 0.7% of those with “inconclusive mammographic lesions”.^6,7

BR-3: Breast Reconstruction

BR-3: Breast Reconstruction

For this condition imaging is medically necessary based on the following criteria:

† CTA or MRA of the body part from which the free tissue transfer flap is being taken, can be performed for breast reconstruction preoperative planning.^2,3

® For example, CTA Abdomen and/or Pelvis (CPT^® 74175 or CPT^® 72191 or CPT^® 74174) or MRA Abdomen and/or Pelvis (CPT^® 74185 and/or CPT^®.72198) for Deep Inferior Epigastric Perforators (DIEP) flap.⁸

BR-4: Breast MRI is NOT Indicated

BR-4: Breast MRI is NOT Indicated

For this condition imaging is medically necessary based on the following criteria:

† MRI Breast should not be used to determine biopsy recommendations for suspicious or indeterminate lesion(s) that can be readily biopsied, either using imaging guidance or physical exam, such as palpable masses and microcalcifications.^3,6

† Members with dense breasts as determined by mammogram

® To date, evidence does not suggest improved outcomes for women whose only risk factor is breast density [See heading “Equivocal or Occult Findings” (Radiologist Report) in BR-5: MRI Breast Indications].^13,14,15

® Repeat the original type study (mammogram, US, or MRI) in 6 months
¡ If repeat imaging remains BI-RADS™ 3, repeat original study at 12 months, 18 months, and 24 months from the date of the initial imaging. After 2 years of stability, the finding should be assessed as benign (Cat 2).¹⁶
¡ If repeat imaging is BI-RADS™ 1 or 2, then imaging reverts to routine per individuals risk profile.

® A lesion categorized as have BI-RADS™ 4 or 5 should be biopsied.¹⁶

® Certain payers do not include breast implants in their coverage policies if the breast implants were placed as part of purely cosmetic surgery. Thus, surveillance MRI in these members would also not be included in the coverage policy. Their coverage policies will take precedence over Horizon BCBSNJ’ guidelines.

BR-5: Breast MRI Indications

BR-5: Breast MRI Indications

For this condition imaging is medically necessary based on the following criteria:

† MRI Breast is indicated for breast augmentation, breast implants (saline or silicone), breast reconstruction, free injection, and capsular contracture to:

® Evaluate or confirm breast implant rupture when mammography or ultrasound is uninterpretable.¹

® MRI Breast is indicated preoperatively to establish extent of disease where a diagnosis of malignant phyllodes tumor has previously been established by tissue diagnosis.^18,19,20 (See Practice Note)

® Radiologist Report Recommendation for MRI Breast and inconclusive or conflicting findings on mammography or ultrasound of a finding that is not a discrete palpable mass.
® A probably benign lesion on MRI (MRI BI-RADS^TM 3) should undergo repeat MRI in 6 months
¡ If repeat imaging remains BI-RADS™ 3, repeat at 12 months, 18 months, and 24 months from the date of the initial imaging. After 2 years of stability, the finding should be assessed as benign (Cat 2).¹⁶
¡ If repeat imaging is BI-RADS™ 1 or 2, then imaging reverts to routine per individuals risk profile.

† Newly Diagnosed Breast Cancer⁴ (including DCIS).^1,6,24,25,26

† Newly Diagnosed Paget’s Disease⁵ (thereafter treat as DCIS according to these guidelines).^26,28

† Residual or Recurrent Malignancy

® Assessment of residual tumor in members who have undergone lumpectomy and have close or positive margins, when the findings may indicate a significant change in surgical management.²⁹
® Evaluate clinical suspicion of recurrence, following evaluations with mammography and/or ultrasound, if those evaluations are inconclusive or conflict with physical examination or other clinical indicators. This applies to intact breasts, reconstructed breasts, and possible chest wall recurrences following mastectomy.²⁹

† State Specific Density Reporting and Imaging Mandate Laws

† For members or covered persons in benefit plans that are subject to the New Jersey breast cancer screening mandate (P.L.2017, c.305)and for ASO/ASC/self-funded groups which opted to adopt the New Jersey breast cancer screening mandate, coverage includes ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the member has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the member's health care provider.

® Phyllodes tumor is usually benign and has clinical characteristics of fibroadenoma, although they may exhibit rapid growth. Breast MRI has not been shown to be of value in distinguishing fibroadenoma from phyllodes tumor.
® Diagnosis is made by tissue diagnosis (percutaneous core biopsy or excisional biopsy). FNA biopsy is inaccurate in phyllodes tumor diagnosis and is not recommended.
® Treatment is wide local excision. Axillary lymph node dissection is not necessary. It has a predilection for local recurrence following local excision.
® If biopsy establishes a diagnosis of malignant phyllodes (cystosarcoma phyllodes), it should be treated as a soft tissue sarcoma (See Adult Oncology Imaging Policy (Policy #155 in the Radiology Section); ONC-12: Sarcomas – Bone, Soft Tissue and GIST).^18,19,20

BR-6: Nipple Discharge/Galactorrhea

BR-6: Nipple Discharge/Galactorrhea

For this condition imaging is medically necessary based on the following criteria:

® If the nipple discharge is pathologic, ductography should be attempted.
® If mammogram and ultrasound are negative, and ductography is unavailable or technically limited, MRI Breast can be performed.^31,32,33,34

† Mammogram and ultrasound (CPT^® 76641: unilateral, complete or CPT^® 76642: unilateral, limited) should be obtained as initial imaging, with clinical pathway determined by results.^31,32,33,34

† If nipple discharge is physiologic, there are no suspicious findings on clinical exam, and mammogram and ultrasound are negative, no additional imaging is necessary, and the member can be reassured.^31,32,33,34

Nipple Discharge/Galactorrhea - Practice Notes

† For milky discharge, prolactin and TSH levels are recommended to diagnose prolactinoma; pituitary imaging is not needed if normal serum Prolactin..

BR-7: Breast Pain (Mastodynia)

BR-7: Breast Pain (Mastodynia)

For this condition imaging is medically necessary based on the following criteria:

† Mammogram and ultrasound are the initial imaging for breast pain.³⁹

† Advanced imaging is NOT routinely indicated in members with breast pain and negative evaluation (evaluation includes member history and physical exam, pregnancy test, mammogram and ultrasound (CPT^® 76641: unilateral, complete or CPT^® 76642: unilateral, limited).³⁹

® If evaluation is not negative, See BR-5: MRI Breast Indications

BR-8: Alternative Breast Imaging Approaches

BR-8: Alternative Breast Imaging Approaches

For this condition imaging is medically necessary based on the following criteria:

† New and/or alternative breast imaging techniques include:

® Nuclear breast imaging, including:
¡ Scintimammography
¡ Molecular breast imaging (MBI)
¡ Breast specific gamma imaging (BSGI)
® PET Mammography (PEM)
® Thermography
® Impedance Mammography
® Other techniques to detect oxygen consumption, light absorption, microwave transmission, nitrous oxide production
® CT Breast
® Coned Beam CT Breast

Alternative Breast Imaging Approaches - Practice Notes

† Positron Emission Mammography

® There is currently insufficient data available to generate appropriateness criteria for this modality, and this procedure should be considered investigational at this time
¡ High-resolution positron-emission mammography (PEM) by Naviscan™ PET Systems, also referred to as Naviscan™ or PET mammography, performs high- resolution metabolic imaging for breast cancer using an FDG tracer. The PEM detectors are integrated into a conventional mammography system, allowing acquisition of the emission images immediately after the mammogram.
¡ Requesting providers often ask for PEM as CPT^® 78811 or “PET scan of the breast”.
¡ The spatial resolution of this technique is at the individual duct level (1.5 mm) and allows visualization of intraductal as well as invasive breast cancers. This technique is especially adept at detecting ductal carcinoma in situ.
¡ Early clinical trials have shown high clinical accuracy in characterizing lesions identified as suspicious on conventional imaging or physical examination, as well as in detecting incidental breast cancers not seen on other imaging modalities
¡ A prospective multi-center clinical trial for women with newly diagnosed breast cancer anticipating breast-conservation surgery was performed. These women underwent both high-resolution PEM imaging and breast MRI. Results showed that PEM and MRI had comparable breast-level sensitivity, although MRI had greater lesion-level sensitivity and more accurately depicted the need for mastectomy. PEM had greater specificity at the breast and lesion levels. Of these, 3.6% of the women had tumors seen only with PEM.
¡ The radiation exposure from a PEM study is 23 times higher than for digital mammography.

BR-9: Suspected Breast Cancer in Males

For this condition imaging is medically necessary based on the following criteria:

† Breast cancer in men presents as a mass, skin/nipple change, or pathologic nipple discharge.

† For men <25 years of age with an indeterminate palpable mass, ultrasound is recommended as initial imaging followed by mammography if ultrasound is inconclusive or suspicious.

† For men ≥25 years of age with an indeterminate palpable mass or with a concerning physical examination, mammography is recommended initially followed by ultrasound if mammography is inconclusive or suspicious.

† There is limited evidence on the use of MRI in the evaluation of male breast disease.

† Further diagnostic pathway for suspicious clinical or imaging findings usually requires tissue diagnosis.

Medicaid Coverage:

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Adult Breast Imaging
Breast Cancer
Breast Ultrasound
Breast MRI
Mammography

References:

References
1. Final Recommendation Statement: Breast Cancer: Screening. U.S. Preventive Services Task Force. November 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening.
2. Mainiero MB, Lourenco A, Mahoney MC, et al. ACR Appropriateness Criteria^® Breast cancer screening. Journal of the American College of Radiology. 2013; 10(1):11-14.
3. Sprague BL, Stout NK, Schechter C, et al. Benefits, harms, and cost-effectiveness of supplemental ultrasonography screening for women with dense breasts. Ann Intern Med. 2015; 162(3):157-166.
4. Mendelson EB, Böhm-Vélez M, Berg WA, et al. ACR BI-RADS^® Ultrasound. In: ACR BI-RADS^® Atlas, Breast imaging reporting and data system. Reston, VA, American College of Radiology. 2013.
5. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2017 – May 17, 2017. Thyroid Carcinoma. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer Screening and Diagnosis 2.2017. ^©2017 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
6. Peters NHG, Borel Rinkes IHM, Zuithoff NPA, et al. Meta-analysis of MR imaging in the diagnosis of breast lesions. Radiology 2008; 246(1).
7. Moy L, Elias K, Patel V, et al. Is Breast MRI helpful in the evaluation of inconclusive mammographic findings? American Journal of Roentgenology. 2009; 193(4):986-993.
8. Pinel-Giroux FM, El Khoury MM, Trop I, et al. Continuing medical education: breast reconstruction: review of surgical methods and spectrum of imaging findings. Radiographics. 2013; 33(2):435-453.
9. Dorrius MD, Van der Weide MCJ, van Ooijen PMA, et al. Computer-Aided Detection in Breast MRI: A systematic review and meta-analysis. Eur Radiol. August 2011; 21(8):1600–1608..
10. Lehman CD, Blume JD, DeMartini WB, et al. Accuracy and interpretation time of computer-aided detection among novice and experienced breast MRI readers. American Journal of Roentgenology 2013; 200(6):W683–W689.
11. NCCN Guidelines Version 2.2017. Invasive Breast Cancer: Principles of Dedicated Breast MRI Testing. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2017: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 2.2017 ^©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
12. Saslow D, Boetes C, Burke W, et al. American Cancer Society Guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007; 57(2):75-89.
13. Emaus MJ, Bakker MF, Peeters PHM, et al. MR Imaging as an additional screening modality for the detection of breast cancer in women aged 50-75 years with extremely dense breasts: The DENSE trial study design. Radiology. 2015; 277(2).
14. American College of Obstetricians and Gynecologists. Management of women with dense breasts diagnosed by mammography. Committee Opinion No. 625 American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 125. https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Women-With-Dense-Breasts-Diagnosed-by-Mammography#here.
15. Siu AL. Screening for breast cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2016; 164(4):279-296.
16. Sickles EA and D’Orsi CJ. ACR BI-RADS^® Follow-up and Outcome Monitoring. In: ACR BI-RADS^® atlas, breast imaging reporting and data system. American College of Radiology. 2013.
17. McCarthy CM, Pusic A, and Kerrigan CL. Silicone breast implants and magnetic resonance imaging screening for rupture: do U.S. food and drug administration recommendations reflect an evidence-based practice approach to patient care? Plastic & Reconstructive Surgery: April 2008; 121(4):1127-1134.
18. Holmich LR, Vejborg I, Conrad C, et al. Untreated Silicone Breast Implant Rupture, Plastic & Reconstructive Surgery: July 2004; 114(1):204-214.
19. Grau AM, Bapsi C, Chugh R, et al. Phyllodes tumors of the breast. UpToDate, 6/2017.
20. Tan H, Zhang S, Liu H, et al, Imaging findings in phyllodes tumors of the breast. Eur J Radiol. Jan 2012; 81(1):e62-69..
21. NCCN Guidelines Version 2.2017: Phyllodes Tumor National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2017: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 2.2017 ^©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
22. NCCN Guidelines Version 1.1017: Breast Cancer Risk Reduction National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2017: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 2.2017 ^©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
23. Morris EA, Comstock CE, Lee CH, et al. ACR BI-RADS^® Magnetic Resonance Imaging. In: ACR BI-RADS^® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology. 2013.
24. Institute for Clinical Systems Improvement (ICSI). Diagnosis of breast disease. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 45 p.
25. NCCN Guidelines Version 2.2017: Ductal Carcinoma in Situ. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2017: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 2.2017 ^©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
26. NCCN Guidelines Version 2.2017: Invasive Breast Cancer National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2017: Breast Cancer. Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 2.2017 ^©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
27. Lehman CD, Gatsonis C, Kuhl CK, et al. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007 March; 356(13):1295-1303.
28. NCCN Guidelines Version 2.2017: Paget’s Disease. National Comprehensive Cancer Network (NCCN) Guidelines Version 2.2017: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 2.2017 ^©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
29. Lim HS et al. Paget Disease of the breast: mammographic, US, and MR imaging findings with pathologic correlation. Radiographics. 2011; 31(7); 1973-1987.
30. Moy L, Newell MS, Mahoney MC, et al. ACR Appropriateness criteria stage I breast cancer: initial workup and surveillance for local recurrence and distant metastases in asymptomatic women. Journal of the American College of Radiology. 2016; 13(11):43-52.
31. NCCN Guidelines Version 3.2019. Genetic/Familial High-Risk Assessment: Breast and Ovarian. National Comprehensive Cancer Network (NCCN) Guidelines Version 3.2019: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 3.2019 ^©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
32. Lee SJ, Trikha S, Moy L, et al. ACR Appropriateness Criteria^® Evaluation of Nipple Discharge. Journal of the American College of Radiology. 2017; 14(5):138-153.
33. Berger N, Luparia A, Di G, et al. Diagnostic Performance of MRI versus galactography in women with pathologic nipple discharge: a systematic review and meta-analysis. AJR. American Journal of Roentgenology. August 2017; 209(2):465-471.
34. Bahl M, Gadd MA, Lehman CD. Diagnostic utility of MRI after negative or inconclusive mammography for the evaluation of pathologic nipple discharge. American Journal of Roentgenology. 2017; 209(6):1404-1410.
35. Morrogh M, Morris EA, Liberman L, et al. The predictive value of ductography and magnetic resonance imaging in the management of nipple discharge. Ann Surg Oncol. 2007; 14; 3369.
36. Expert Im, Mainiero MB, Moy L, et al. ACR Appropriateness Criteria^® Breast Cancer Screening. American College of Radiology. 14(11s):s383-s390.
37. Berg WA. Current status of dedicated nuclear breast imaging. Society of breast imaging white paper. Journal of Nuclear Medicine.2016 Feb; 57(Supplement 1):46S-52S..
38. Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol. 2010; 7(1):18-27.
39. Expert Im, Jokich PM, Bailey L, et al. ACR Appropriateness Criteria^® Breast Pain. American College of Radiology. 2014(5S).
40. Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR. Journal of the American College of Radiology. 2018;15(3):408-414.
41. Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/genomics/gtesting/file/print/fbr/BCAnaVal.pdf.
42. NCCN Guidelines Version 3.2018, Breast Cancer Screening and Diagnosis. National Comprehensive Cancer Network (NCCN) Guidelines Version 3.2018: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 3.2018 ^©2018 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
43. NCCN Guidelines Version 3.2019, Genetic/Familial High Risk Assessment: Breast and Ovarian. National Comprehensive Cancer Network (NCCN) Guidelines Version 3.2019: Breast Cancer. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for Breast Cancer 3.2019 ^©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.
44. Koning Breast CT. Koning Corporation. http://koninghealth.com/en/kbct/. Accessed March 18, 2019.
45. Golan O, Amitai Y, Barnea Y, Menes TS. Yield of surveillance magnetic resonance imaging after bilateral mastectomy and reconstruction: a retrospective cohort study. Breast Cancer Research and Treatment. 2018;174(2):463-468. doi:10.1007/s10549-018-05077-9.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*
76641
76642
76882
77058
77059
19085
19086
74175
72191
74185
72198
76376
76377