Oscar Breast Imaging (CG027) Form

The Plan

The Plan considers breast mammography, breast ultrasound, and breast MRI medically necessary as screening modalities in patients meeting certain risk criteria (described below). These modalities and breast PET are also used as a diagnostic tool, typically for the purpose of breast cancer evaluation and staging.

Definitions

• Mammography is an imaging modality that uses X-rays to study breast tissue for screening or diagnostic purposes. The diagnostic mammogram often requires additional views and is interpreted in real-time by a radiologist.
• Breast Tomosynthesis (3D mammography, digital mammography) is an imaging modality that uses a moving X-ray source to create a three dimensional view of the breast tissue, as opposed to a two dimensional view provided by a standard mammogram.
• Breast Ultrasound is an imaging modality that uses sound waves to evaluate the breast tissue, usually in the setting of diagnostic follow up to concerning areas found on previous imaging, focal breast symptoms in women under 30, or guidance for biopsy or aspiration procedures.
• Automated breast ultrasound (ABUS) is a technique similar to a standard handheld breast ultrasound, except an automated transducer is used to standardize the image acquisition process.
• Breast MRI is an imaging modality that utilizes magnets to provide a detailed picture of breast tissue, usually in the setting of existing breast cancer or assessment of silicone implants.
• Breast PET is an imaging modality that uses an injected radiotracer to highlight abnormal areas in the breast that might harbor cancer cells. It is often combined with a CT scan for better anatomic delineation.
• Computer-Aided Detection is the use of specialized software to help analyze ultrasound, mammography, or MRI breast images with the goal of decreasing the time to read and interpret images.

Clinical Indications

• Mammography (Digital or Film Screen)

  The Plan considers mammography medically necessary for higher risk or average risk (no prior history or risk factors) members when the criteria outlined in MCG Mammography (A-0039) are met. Please refer to your plan benefits for eligibility by age for members younger than 40 years old (average risk) for breast cancer screening.

• Breast Tomosynthesis (3D Mammography)

  The Plan considers breast tomosynthesis (3D mammography) medically necessary for higher risk or average risk (no prior history or risk factors) members when the criteria outlined in MCG Mammography (A-0039) are met. Please refer to your plan benefits for eligibility by age for members younger than 40 years old (average risk) for breast cancer screening.

• Breast MRI

  The Plan considers breast MRI medically necessary when the criteria outlined in MCG Breast MRI (A-0048) are met.

• Breast Ultrasound

  The Plan considers breast ultrasound medically necessary when the criteria outlined in MCG Breast Ultrasound (A-0101) are met.

• Breast Positron Emission Tomography (PET) scan

  The Plan considers breast PET scans medically necessary when the criteria outlined in MCG Tumor Imaging Positron Emission Tomography (PET) and PET-CT (A-0098) are met for diagnostic purposes. PET scans for breast cancer screening are considered not medically necessary. Furthermore, certain PET diagnostic procedures are considered experimental or investigational, please see applicable billing codes below.

Experimental or Investigational / Not Medically Necessary

• Breast MRI
  • The Plan does NOT consider medically necessary breast MRI for the screening or initial evaluation of saline implant rupture related to a solely cosmetic breast implant not associated with a medically necessary breast reconstruction procedure. This policy is in accordance with numerous professional societies.
  • The Plan does NOT consider medically necessary routine MRI surveillance of asymptomatic, average-risk patients with a history of breast cancer who have successfully completed primary therapy. The National Comprehensive Cancer Network (NCCN) guidelines for breast cancer do NOT include MRI in the recommendations for surveillance or follow-up after treatment. NCCN recommends mammogram every 12 months. The American Society of Breast Surgeons similarly, do not have recommendations regarding routine MRI in the surveillance/follow up of breast cancer.
• Transillumination

  The Plan does NOT consider medically necessary transillumination for breast imaging as it has not been established as an effective technique and is therefore considered experimental and investigational.

• Electrical Impedance Scanning (EIS)

  The Plan does NOT consider medically necessary electrical impedance scanning for breast imaging as this technique has not demonstrated improved effectiveness compared to mammography alone and is considered experimental and investigational.

• Elastography

  The Plan does NOT consider medically necessary magnetic resonance elastography or ultrasound elastography as it has not been demonstrated to be superior to MRI or ultrasound alone in breast surveillance. The accuracy of elastography remains unproven for breast cancer.

• Breast Specific Gamma Imaging (Molecular Breast Imaging) / Scintimammography

  The Plan does NOT consider medically necessary breast specific gamma imaging (BSGI) used for Scintimammography examination as current studies do not provide conclusive evidence that breast-specific gamma imaging can be relied on rather than biopsy, US, or MRI in women who have suspicious breast lesions on mammograms.
  Most recently the American College of Radiology reiterated that the current evidence is insufficient to recommend BSGI in the imaging algorithm of breast cancer. In the latest 2021 American College of Radiology Appropriateness Criteria, Sestamibi molecular breast imaging was usually not appropriate for breast cancer screening. BSGI remains as a limited adjunctive tool to standard mammograms, ultrasound, and MRI.

• Computer-Aided Detection for MRI and Ultrasound

  The Plan does NOT consider medically necessary computer-aided detection for MRI and ultrasound. Although this technology remains promising for the future, there currently is insufficient evidence to recommend its use.

• Computer-Aided Tactile Breast Imaging

  The Plan does NOT consider medically necessary computer-aided tactile breast imaging for breast applications. Studies have failed to show an improvement compared to conventional modalities.

• Automated Breast Ultrasound

  The Plan does NOT consider medically necessary Automated Breast Ultrasound for breast imaging. This system did receive FDA approval based mainly on the safety of the technique, but its effectiveness remains questionable. The studies to date have suffered from a high prevalence of cancer in the study populations which limits the generalizability of the findings to the general population for screening purposes. Current guidelines by the American College of Radiology and the American Society of Breast Surgeons make no mention of automated breast ultrasound in their recommendations. An UpToDate review on breast imaging notes a lack of clear evidence but that the two techniques may be comparable. Furthermore, the largest study to date on 15,318 women concluded that "Addition of AB US to screening mammography in a generalizable cohort of women with dense breasts increased the cancer detection yield of clinically important cancers, but it also increased the number of false-positive results."

• Positron Emission Tomography (PET) scan, including with 18F and 18F-fluoroestradiol tracers for Breast Cancer Screening

  The Plan does NOT consider medically necessary PET-based imaging (e.g., PET, PET-CT, PET-MRI, etc.) for breast imaging as part of breast cancer screening. NCCN guidelines for breast cancer screening do not list PET as an option. USPSTF and ACS does not list PET under breast cancer screening recommendations. PET imaging may be medically necessary for members who have already been diagnosed with breast cancer and require further workup or staging.