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Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-58 Radioactive Seed Localization of Nonpalpable Breast Lesions Form


Radioactive Seed Localization of Nonpalpable Breast Lesions

Indications

(453074) Is the radioactive seed localization procedure being performed to localize a nonpalpable breast lesion in advance of surgical excision? 
(453075) Is radioactive seed localization used to assist in targeted excision of positive axillary lymph nodes after neoadjuvant therapy? 

Contraindications

(453076) Is the radioactive seed localization being used to localize palpable breast lesions? 
Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses the use of radioactive seed localization (RSL). This is a technique used to provide localization of nonpalpable breast lesions before breast-conserving surgery. It can be used as an alternative to wire localization (WL) or radio-guided occult lesion localization.

Clinical Indications

Medically Necessary:

Radioactive seed localization of nonpalpable breast lesions is considered medically necessary as a method to localize a nonpalpable breast lesion in advance of surgical excision.

Radioactive seed localization is considered medically necessary to assist in targeted excision of positive axillary lymph nodes after neoadjuvant therapy.

Not Medically Necessary:

The use of radioactive seed localization is considered not medically necessary when the criteria above have not been met, including but not limited to use as a method to localize palpable breast lesions.