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Medical Policy: 06.01.25
Original Effective Date: March 2007
Reviewed: June 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Computer aided detection (CAD) systems use proprietary computerized algorithms to assess mammography images for patterns that may represent microcalcifications or masses that may be indicative of breast cancer. The system provides the radiologist with a printed or digital image upon which suspicious areas are marked so that comparison can be made to the patient’s original mammogram. The CAD systems are not intended to replace mammograms, but are intended as an alternative to double-readings, or the practice of having a second radiologist interpret the mammogram. CAD is used only after a standard mammogram is completed.
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Prior Approval:
Not applicable
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Policy:
Computer-aided detection systems as an adjunct to single-reader interpretations of screening or diagnostic mammograms may be considered medically necessary.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- CPT 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)
- CPT 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 film radiographic images; screening mammography (List separately in addition to code for primary procedure)
- CPT 77055 Mammography; unilateral
- CPT 77056 Mammography; bilateral
- CPT 77057 Screening mammography, bilateral (2-view film study of each breast
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Selected References:
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Gur D, Sumkin JH, Rockette HE et al. Changes in breast cancer detection and mammography recall rates after the introduction of a computer-aided detection system. J Natl Cancer Inst. 2004 Feb 4; 96(3):185-90.
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Baum F, Fischer U, Obenauer S et al. Computer-aided detection in direct digital full-field mammography: initial results. Eur Radiol 2002; 12:3015-17.
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Taplin SH, Rutter CM, Lehman CD. Testing the effect of computer-assisted detection on interpretive performance in screening mammography. AJR 2006; 187: 1475-82.
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Ko JM, Nicholas MJ, Mendel JB et al. Prospective assessment of computer-aided detection in interpretation of screening mammography. AJR 2006; 187: 1483-91.
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Birdwell RL, Bandodkar P, Ikeda DM. Computer-aided detection with screening mammography in a university hospital setting. Radiology. 2005; 236(2):451-7.
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Pisano ED, Yaffe MJ. Digital Mammography. Radiology 2005; 234: 353-62.
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2002 Technology Evaluation Center Assessment: Computer-aided Detection in Mammography. Blue Cross Blue Shield Association.
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2006 Technology Evaluation Center Assessment: Computer-aided Detection with Full-Field Digital Mammography. Blue Cross Blue Shield Association.
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Obenauer S, Sohns C, Werner C et al. Computer-aided detection in full-field digital mammography. Breast J 2006 Jan-Feb; 12(1):16-9.
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Fenton JJ, Taplin SH, Carney PA et al. Influence of computer-aided detection on performance of screening mammography. N Engl J Med. 2007 Apr 5;356(14):1399-409.
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Taylor P, Potts HW. Computer aids and human second reading as interventions in screening mammography: two systematic reviews to compare effects on cancer detection and recall rate. Eur J Cancer. 2008 Apr;44(6):798-807. Epub 2008 Mar 18.
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Skaane P, Kshirsagar A, Stapleton S et al. Effect of computer-aided detection on independent double reading of paired screen-film and full-field digital screening mammograms. AJR Am J Roentgenol. 2007 Feb; 188(2):377-84.
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Georgian-Smith D, Moore RH, Halpern E et al. Blinded comparison of computer-aided detection with human second reading in screening mammography. AJR Am J Roentgenol. 2007 Nov;189(5):1135-41.
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Gromet M. Comparison of computer-aided detection to double reading of screening mammograms: review of 231,221 mammograms. AJR Am J Roentgenol. 2008 Apr;190(4):854-9.
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Sadaf A, Crystal P, Scaranelo A et al. Performance of computer-aided detection applied to full-field digital mammography in detection of breast cancers. Eur J radiol. 2009 Oct 27. [Epub ahead of print].
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Cawson JN, Nickson C, Amos A et al. Invasive breast cancers detected by screening mammography: a detailed comparison of computer-aided detection-assisted single reading and double reading. J Med Imaging Radiat Oncol. 2009 Oct;53(5):442-9.
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Paquerault S, Samuelson FW, Petrick N et al. Investigation of reading mode and relative sensitivity as factors that influence reader performance when using computer-aided detection software. Acad Radiol. 2009 Sep;16(9):1095-107. Epub 2009 Jun 11.
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Noble M, Bruening W, Uhl S et al. Computer-aided detection mammography for breast cancer screening: systematic review and meta-analysis. Arch Gynecol Obstet. 2009 Jun; 279(6):881-90. Epub 2008 Nov 21.
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James JJ, Gilbert FJ, Wallis MG et al. Mammographic features of breast cancers at single reading with computer-aided detection and at double reading in a large multicenter prospective trial of computer-aided detection: CADET II. Radiology 2010 Aug;256(2):379-86.
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Policy History:
Date Reason Action
June 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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