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Medical Policy: 06.01.07
Original Effective Date: January 2002
Reviewed: February 2012
Revised: April 2008
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:
Magnetic resonance imaging (MRI) of the breast is performed using MR scanners and intravenous contrast agents. Specialized breast coils are usually used. This policy addresses several clinical indications including screening, detection and diagnosis of breast cancer. In light of the evolving nature of this technology the peer-reviewed literature is frequently scanned for additional evidence-based clinical indications.
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Prior Approval:
Not applicable
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Policy:
Screening Uses
MRI of the breast may be considered medically necessary for the following indications for screening for breast cancer in the following patients:
- Those with a known BRCA 1 or BRCA 2 mutation
- Those at high-risk of BRCA 1 or BRCA 2 mutation due to a known presence of the mutation in relatives
- Those with a pattern of breast cancer history in multiple first-degree relatives, often occurring at a young age and with bilaterality, consistent with a high probability of harboring BRCA mutations or other hereditary breast cancer.
- Those who have Li-Fraumeni syndrome or Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or who have a first-degree relative with one of these syndromes
- Those at high-risk (defined as a lifetime risk about 20% to 25% or greater) of developing breast cancer as identified by models, such as BRCAPRO, that are largely dependent on family history
- Those who have received radiation therapy to the chest wall between the ages of 10 and 30 years
Detection Uses
MRI of the breast may be considered medically necessary for the following indications for detection:
- Suspected occult breast primary tumor in patients with axillary nodal adenocarcinoma when mammography and physical exam are negative
- Suspected silicone or saline implant rupture if the original implant surgery was not performed for cosmetic purposes
- In the contralateral breast of a patient with breast cancer when the physical exam and mammography are negative or inconclusive
- Post-lumpectomy with close or positive pathological margins to evaluate the presence of residual disease
Diagnostic Uses
MRI of the breast may be considered medically necessary for the following diagnostic indications:
- Pre-surgical planning to evaluate the presence of multicentric disease in patients with locally advanced cancer who are candidates for breast conservation treatment (BCT)
- Pre-surgical planning in patients with locally advanced cancer before and after adjuvant chemotherapy to permit tumor localization and characterization
- To determine presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumor(s)
- To further characterize indeterminate or suspicious breast lesions when primary screening results and physical examination are inconclusive for breast cancer
Screening Uses
- MRI of the breast is considered investigational as a screening technique in women not meeting the screening criteria listed above, because the direct benefit of MRI screening over mammography has not been proven outside those indications.
Diagnostic Uses
- MRI of the breast is considered investigational for diagnosis of low-suspicion findings on conventional testing not indicated for immediate biopsy. The available studies do not compare the sensitivity and specificity of short-interval mammographic follow-up and MRI to determine the effects this adjunctive use of MRI has on health outcomes.
- MRI of the breast is considered investigational for diagnosis of a suspicious breast lesion in order to avoid biopsy.
- MRI of the breast is considered investigational as a technique to evaluate response during neoadjuvant chemotherapy. The available evidence is limited. Results are inconsistent and there is insufficient evidence to determine whether MRI can reliably predict lack of response to chemotherapy.
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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 diagnostic codes.
- 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
- 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 (List separately in addition to code for primary procedure)
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Selected References:
- Liberman L, Morris EA, Kim CM et al. MR imaging findings in the contralateral breast of women with recently diagnosed breast cancer. AJR Am J Roentgenol 2003; 180(2):333-41.
- Lee SG, Orel SG, Woo IJ et al. MR imaging screening of the contralateral breast in patients with newly diagnosed breast cancer; preliminary results. Radiology 2003; 226(3):77308.
- Drew PJ, Kerin MJ, Mahapatra T et al. Evaluation of response to neoadjuvant chemoradiotherapy for locally advanced breast cancer with dynamic contrast-enhanced MRI of the breast. Eur J Surg Oncol 2001; 27(7):617-20.
- Partridge SC, Gibbs JE, Lu Y et al. Accuracy of MR imaging for revealing residual breast cancer in patients who have undergone neoadjuvant chemotherapy. AJR Am J Roentgenol 2002; 179(5):1193-9.
- Morris EA, Schwartz LH, Drotman MB, et al. Evaluation of pectoralis major muscle in patients with posterior breast tumors on MR images: early experience. Radiology 2000; 214(1):67-72.
- Kerslake RW, Carleton PJ, Fox JN et al. Dynamic gradient-echo and fat-suppressed spin-echo contrast-enhanced MRI of the breast. Clin Radiol 1995; 50(7):440-54.
- Lee JM, Orel SG, Czerniecki BJ et al. MRI before reexcision surgery in patients with breast cancer. AJR Am J Roentgenol 2004; 182(2):473-80.
- Bedrosian I, Mick R, Orel SG, et al. Changes in surgical management of patients with breast carcinoma based on preoperative magnetic resonance imaging. Cancer 2003; 98(3):468-73.
- Kawashima H, Tawara M, Suzuki M et al. Effectiveness of dynamic MRI for diagnosing pericicatricial minimal residual breast cancer following excisional biopsy. Eur J Radiol 2001; 40(1):2-9.
- Weinstein SP, Orel SG, Heller R et al. MR imaging of the breast in patients with invasive lobular carcinoma. AJR Am J Roentgenol 2001; 176(2):399-406.
- Leonard GD, Swain SM. Ductal carcinoma in situ, complexities and challenges. J Natl Cancer Inst. 2004 Jun 16; 96(12):906-20.
- Warner, E, Plewes DB, Hill KA et al. Surveillance of BRCA1 and BRCA2 Mutation Carriers with Magnetic Resonance Imaging, Ultrasound, Mammography, and Clinical Breast Examination. JAMA 2004 292(11) 1317-25.
- Berg WA, Gutierrez L, NessAiver MS et al. Diagnostic Accuracy of Mammography, Clinical Examination, US, and MR Imaging in Preoperative Assessment of Breast Cancer. Radiology 2004; 233:830-49.
- Lehman CD, Blume JD, Thickman D et al. Added cancer yield of MRI in screening the contralateral breast of women recently diagnosed with breast cancer: results from the International Breast Magnetic Resonance Consortium (IBMC) trial. J Surg Oncol. 2005 Oct. 1; 92(1):9-15.
- Frei KA, Kinkel K, Bonel HM et al. MRI Imaging of the Breast in Patients with Positive Margins after Lumpectomy: Influence of the Time Interval between Lumpectomy and MR Imaging. AJR Am J Roentgenol. 2000 Dec; 175(6):1577-84.
- American College of Radiology (ACR) Practice Guideline for the Performance of Magnetic Resonance Imaging of the Breast. Eff. 10/1/04. ACR website accessed 12/05/2005.
- 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 May-Jun; 57(3):75-89.
- Dunfield L, Severn M. Effectiveness of magnetic resonance imaging (MRI) screening for women at high risk of breast cancer [Technology report number 93]. Ottawa: Canadian Agency for Drugs and Technologies in health; 2007 http://www.cadtha.ca, accessed on April 10, 2008.
- Loo CE, Straver ME, Rodenhuis S et al. Magnetic resonance imaging response monitoring of breast cancer during neoadjuvant chemotherapy: relevance of breast cancer subtype. J Clin Oncol 2011 Feb 20; 29(6):660-66. doi: 10.1200/JCO.2010.31.1258.
- Painter TJ, Dipasco PJ, Misra S, et al. Effect of magnetic resonance imaging on breast conservation therapy versus mastectomy: a review of the literature. Int J Surg Oncol. 2011; doi: 10.1155/2011/428653
- Gold LS, Klein G, Carr L et al. The emergence of diagnostic imaging technologies in breast cancer: discovery, regulatory approval, reimbursement, and adoption in clinical guidelines. Cancer Imaging. 2012 Jan 25; 12(1):13-24.
- Drukteinis JS, Gombos EC, Raza S et al. MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions. Radiographics. 2012 Jan; 32(1):219-34.
- Valente SA, Levine GM, Silverstein MJ et al. Accuracy of predicting axillary lymph node positivity by physical examination, mammography, ultrasonography, and magnetic resonance imaging. Ann Surg Oncol. 2012 Jan 7 [Epub ahead of print].
- Lau B, Romero LM. Does preoperative magnetic resonance imaging beneficially alter surgical management of invasive lobular carcinoma? Am Surg. 2011 Oct; 77(10):1368-71.
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Policy History:
Date Reason Action
March 2011 Annual review Policy renewed
February 2012 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 © 2012 American Medical Association. All Rights Reserved.
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