«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»
CA Cancer J Clin. 2003 May-Jun;53(3):141-69.
Society of Nuclear Medicine (SNM) [Web site] Procedure Guideline for Breast Scintigraphy. 2004.
Breast Imaging- Commercial Medical Management Guideline Available at: http://interactive.snm.org/docs/Breast_v2.0.pdf. Accessed February 2008.
Soderstrom CE, Harms SE, Farrell RS et al. Detection with MR imaging of residual tumor in the breast soon after surgery. AJR 1997;168:485-8.
Tafra L, Cheng Z, Uddo J, Lobrano MB, Stein W, Berg WA, Levine E, Weinberg IN, Narayanan D, Ross E, Beylin D, Yarnall S, Keen R, Sawyer K, Van Geffen J, Freimanis RL, Staab E, Adler LP, Lovelace J, Shen P, Stewart J, Dolinsky S. Pilot clinical trial of 18F-fluorodeoxyglucose positronemission mammography in the surgical management of breast cancer. Am J Surg. 2005 Oct;190(4):628-32.
Technology Evaluation Center (TEC) Blue Cross Blue Shield Association (BCBSA) [Web site] FullField Digital Mammography. February 2006a. Available at http://www.bcbs.com/betterknowledge/tec /vols/20/20_16.html. Accessed February 2008.
Technology Evaluation Center (TEC) Blue Cross Blue Shield Association (BCBSA) [Web site]
Computer-Aided Detection (CAD) with Full-Field Digital Mammography. May 2006b. Available at:
http://www.bcbs.com /betterknowledge/ tec/vols/21/21_03.html. Accessed February 2008.
Technology Evaluation Center (TEC) Blue Cross Blue Shield Association (BCBSA) [Web site] Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast. June 2006c. Available at: http://www.bcbs.com/betterknowledge/tec/vols/21/21_04.pdf. Accessed February 2008.
Tilanus-Linthorst MM, Obdeijn IM, Bartels KC, et al. First experiences in screening women at high risk for breast cancer with MR imaging. Breast Cancer Res Treat. 2000;63(1):53-60.
Trecate G, Vergnaghi D, Manoukian S, Bergonzi S, Scaperrotta G, Marchesini M, Ferranti C, Peissel B, Spatti G, Bohm S, Conti A, Costa C, Sporeni M, Podo F, Musumeci R. MRI in the early detection of breast cancer in women with high genetic risk. Tumori. 2006 Nov-Dec;92(6):517-23.
Vacek PM, Geller BM. A prospective study of breast cancer risk using routine mammographic breast density measurements. Cancer Epidemiol Biomarkers Prev 2004;13:715-722.
Van, GM, Schelfout, K, Kersschot, E, Colpaert, C, Verslegers, I, Biltjes, I, Tjalma, WA, De, SA, Weyler, J, and Parizel, PM. MR mammography is useful in the preoperative locoregional staging of breast carcinomas with extensive intraductal component. Eur J Radiol 2007;62(2):273-282 Vargas, HI, Vargas, MP, Eldrageely, K, Gonzalez, KD, Burla, ML, Venegas, R, and Khalkhali, I.
Outcomes of surgical and sonographic assessment of breast masses in women younger than 30. Am Surg. 2005;71(9):716-719.
Breast Imaging- Commercial Medical Management Guideline Viehweg P, Rotter K, Laniado M, Lampe D, et al. MR imaging of the contralateral breast in patients after breast-conserving therapy. Eur Radiol. 2004 Mar;14(3):402-8.
Warner E, Plewes DB, Hill KA, Causer PA, Zubovits JT, Jong RA, Cutrara MR, DeBoer G, Yaffe MJ, Messner SJ, Meschino WS, Piron CA, Narod SA. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA. 2004 Sep 15;292(11):1317-25.
Warren Burhenne LJ, Wood SA, D'Orsi CJ, et al. Potential contribution of computer-aided detection to the sensitivity of screening mammography. Radiology. 2000;215(2):554-562.
Weinstein SP, Orel SG, Heller R et al. MR imaging of the breast in patients with lobular carcinoma.
Wilkinson, LS, Given-Wilson, R, et al. Increasing the diagnosis of multifocal primary breast cancer by the use of bilateral whole-breast ultrasound. Clin Radiol. 2005;60(5):573-578.
Xydeas T, Siegmann K, Sinkus R, et al. Magnetic resonance elastography of the breast: correlation of signal intensity data with viscoelastic properties. Invest Radiol. 2005 Jul;40(7):412-20.
Yang SK, Moon WK, Cho N, Park JS, Cha JH, Kim SM, Kim SJ, Im JG. Screening mammographydetected cancers: sensitivity of a computer-aided detection system applied to full-field digital mammograms. Radiology. 2007 Jul;244(1):104-11.
History/Updates Policy revision with changes to coverage rationale. Policy held for posting due to 9/16/2008 implementation analysis review. CMS information updated. Policy 2007T0375D archived.
Coding updated. CPT codes 77053 amd 77054 removed. CPT code 78814 added. ICD-9 4/14/2008 coding added.
10/22/2007 The implementation date for computer-aided detection for mammography has been delayed until further notice.
Policy revision with changes to the coverage rationale. CMS section updated with 2007 7/19/2007 CPT codes. CPT codes 77051, 77053, 77054, 77055, 77056, and 77057 added to the CPT coding section. HCPCS code G0202 added to the HCPCS coding section.
Policy revision. Policy combines former policies: Magnetic Resonance Elastography for 6/21/2007
Breast Imaging- Commercial Medical Management Guideline
Breast Cancer (2005T0417B), Computer-Aided Detection for Screening Mammography (2003T0423A), Digital Mammography for Screening and Diagnosing Breast Cancer (2005T0316C), and Magnetic Resonance Imaging (MRI) of the Breast (2005T0375C) which have been archived. CMS information updated. Added CPT code 76645 and HCPCS code S8080. Deleted HCPCS code G0202.
CPT codes 76093 and 76094 deleted. 0159T, 77058 and 77059 added to coding section.
3/29/2007 HCPCS codes C8903, C8904, C8905, C8906, C8907, C8908 removed from the Coding 2/28/2005 Section per direction from the Reimbursement Medical Policy Operations Manager.
CPT codes 76093 and 76094 plus HCPCS codes C8903, C8904, C8905, C8906, C8907, 3/8/2004 C8908 added to Coding Section per direction from the Reimbursement Medical Policy Operations Manager.
Policy reformatted 2/21/2002 Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at firstname.lastname@example.org with the word "Medical" in the subject line.
Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.
0159T Computer aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI 76645 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation 77051 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure) 77052 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of
Breast Imaging- Commercial Medical Management Guideline
film radiographic images; screening mammography (List separately in addition to code for primary procedure) 77055 Mammography; unilateral 77056 Mammography; bilateral 77057 Screening mammography, bilateral (2-view film study of each breast) 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral 77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral 78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) HCPCS Codes G0202 Screening Mammography producing direct digital image,bilateral, all views G0204 Diagnostic Mammography, direct digital image, bilateral, all views G0206 Diagnostic mammography, direct digital image, unilateral, all views S8080 Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical ICD-9 Diagnosis Codes 217 Benign neoplasm of breast 233.0 Carcinoma in situ of breast 238.3 Neoplasm of uncertain behavior of breast 239.3 Neoplasm of unspecified nature of breast 610.0 Solitary cyst of breast 610.1 Diffuse cystic mastopathy 610.2 Fibroadenosis of breast 610.3 Fibrosclerosis of breast 610.4 Mammary duct ectasia 610.8 Other specified benign mammary dysplasias 610.9 Unspecified benign mammary dysplasia
Breast Imaging- Commercial Medical Management Guideline
611.1 Hypertrophy of breast
611.72 Lump or mass in breast
611.79 Other sign and symptom in breast 611.8 Other specified disorder of breast 611.9 Unspecified breast disorder
996.54 Mechanical complication due to breast prosthesis V10.3 Personal history of malignant neoplasm of breast V15.3 Personal history of irradiation, presenting hazards to health V15.89 Other specified personal history presenting hazards to health V16.3 Family history of malignant neoplasm of breast V76.10 Unspecified breast screening V76.11 Screening mammogram for high-risk patient V76.12 Other screening mammogram V76.19 Other screening breast examination V84.01 Genetic susceptibility to malignant neoplasm of breast This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.
Confidential and Proprietary, © UnitedHealthcare, Inc. 2008 Breast Imaging- Commercial Medical Management Guideline TITLE: Cardiac Computed Tomography (CT), Coronary Artery Calcium Scoring and Cardiac CT Angiography Authorized By: Medical Management Guideline Committee
Adoption Date: 08/11/09 Revision Date:
Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.
This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.
Member benefit coverage and limitations may vary based on the member’s benefit plan.
This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.
Cardiac Computed Tomography (CT), Coronary Artery Calcium Scoring and Cardiac CT Angiography - Commercial Medical Management Guideline This policy describes computed tomography (CT) technology used to detect heart disease.
Coverage All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.
Coverage Rationale Calcium scoring Coronary artery calcium scoring, using electron beam or multislice computed tomography 16-slice or greater technology,
is proven for the following:
- risk stratification in asymptomatic patients with moderate risk for coronary heart disease (CHD) based on Framingham score1
- as a triage tool for symptomatic patients to rule out obstructive disease and avoid an invasive procedure Coronary artery calcium scoring is unproven for all other indications, including routine screening.
The evidence indicates that screening asymptomatic adults for coronary heart disease is ineffective and that the harms may outweigh the benefits.
Cardiac CT angiography
Computed tomography angiography (CTA), using 32-slice or greater technology, is proven for assessing the following:
- detecting coronary artery disease in asymptomatic patients with high risk of coronary heart disease (CHD)1
- to rule out coronary artery disease in symptomatic patients with a low to intermediate pre-test probability of coronary artery disease (CAD)2
- chest pain syndrome following a revascularization procedure (stent placement or angioplasty)
- suspected coronary artery anomaly
- preoperative risk assessment for intermediate or high risk non-cardiac surgery3
- morphology of congenital heart disease, including anomalies of coronary circulation, great vessels and cardiac chambers and valves
- assessment of coronary arteries in patients with new onset heart failure to assess etiology
Computed tomography angiography (CTA) is unproven for the following:
- detecting coronary artery disease in symptomatic patients with a high pre-test probability of CAD2
- assessing coronary arteries in symptomatic patients with previously diagnosed CAD