CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Scintimammography / Breast-Specific Gamma Imaging (BSGI) / Molecular Breast Imaging (MBI) coverage policy

This policy governs coverage determinations for scintimammography including Breast-Specific Gamma Imaging (BSGI) and Molecular Breast Imaging (MBI) for evaluation of breast abnormalities and axillary staging; it applies to Medicare Advantage and Commercial products of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyScintimammography / BSGI / MBI coverage policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2019

Next Review DateSep 17, 2025

Key ActionVerify member benefits and eligibility with BCBSRI provider call center before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance

S8080Not covered code

Tc99m sestamibiCommon tracer

≈40 minMBI imaging time

2012-2022Ref. date range

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Coverage Criteria — Scintimammography, BSGI, MBI

General coverage stance

Coverage determinations for scintimammography, BSGI, and MBI:

Not covered / Not medically necessary (Medicare Advantage): For Medicare Advantage Plans: Scintimammography, Breast-Specific Gamma Imaging (BSGI), and Molecular Breast Imaging (MBI) are considered not covered in all applications, including but not limited to their use as an adjunct to mammography or in staging the axillary lymph nodes because the evidence is insufficient to determine the effects of the technology on health outcomes.

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Not medically necessary (Commercial Products): For Commercial Products: Scintimammography, Breast-Specific Gamma Imaging (BSGI), and Molecular Breast Imaging (MBI) are considered not medically necessary in all applications, including but not limited to their use as an adjunct to mammography or in staging the axillary lymph nodes because the evidence is insufficient to determine the effects of the technology on health outcomes.

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Diagnostic accuracy evidence: Diagnostic accuracy studies report negative predictive values for BSGI/MBI ranging approximately from 83% to 94%; the evidence does not demonstrate sufficiently high NPV to alter management compared with standard diagnostic pathways (diagnostic mammography spot views, ultrasound, MRI), supporting the determination of insufficient evidence to improve health outcomes.

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For both Medicare Advantage and Commercial products, all applications of scintimammography, Breast‑Specific Gamma Imaging (BSGI), and Molecular Breast Imaging (MBI) are considered not covered or not medically necessary. This includes, but is not limited to, use as an adjunct to screening or diagnostic mammography and use for staging the axillary lymph nodes, because the available evidence is insufficient to determine effects on health outcomes.

These determinations apply across clinical indications described in this policy; no specific clinical scenarios are identified as covered.

For Commercial products, scintimammography, BSGI, and MBI are considered not medically necessary in all applications, including use as an adjunct to mammography or for axillary lymph node staging due to insufficient evidence of impact on health outcomes.

The policy explicitly lists CPT code S8080 as not medically necessary / not covered for Commercial products when used as described in this policy.

Covered Indications

Evaluation of indeterminate or suspicious breast lesions

Covered when any of the following apply:

Evaluation of indeterminate or suspicious breast lesions: Diagnostic accuracy studies for individuals with indeterminate or suspicious breast lesions report NPV for BSGI/MBI varying from approximately 83% to 94%; however, the available evidence is insufficient to determine effects on health outcomes and does not support routine coverage.

Compare with standard diagnostic modalities (e.g., spot-view mammography, ultrasound, MRI) when considering management decisions.

Not Covered / Not Medically Necessary

Use of scintimammography, BSGI, and MBI as an adjunct to mammography or for staging axillary lymph nodes is not covered / not medically necessary per this policy for the reasons stated above.

CPT/HCPCS coding note: S8080 (Scintimammography [radioimmunoscintigraphy of the breast], unilateral, including of radiopharmaceutical axillary supply) is specifically listed as not covered / not medically necessary for these uses.

Coding and Technical Notes

Not covered / Not medically necessary CPT/HCPCSCPTNot Covered

S8080

Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including of radiopharmaceutical axillary supply

Lesion size sensitivity — reduced sensitivity for lesions smaller than 15 mm

Sensitivity thresholdReduced sensitivity for lesions smaller than 15 mm

Typical radiotracerTechnetium Tc99m sestamibi

Typical MBI exam durationApproximately 40 minutes

ImplicationConventional gamma cameras have relatively poor resolution for small breast lesions; BSGI/MBI were developed to improve resolution

Provider Actions, Billing, and Authorization

Prior Authorization

Prior authorization is not applicable for scintimammography / BSGI / MBI per this document.

Note

Benefit and Eligibility Limitation

Coverage and payment are subject to the member's benefits, eligibility, and the terms of the Evidence of Coverage / Subscriber Agreement or employer agreement. Benefits may vary between groups and contracts; refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage determinations.

Documentation Required

Verify Benefits and Obtain Consent

Verify member-specific benefits and eligibility with the BCBSRI provider call center prior to providing services. If services are determined to be not covered or not medically necessary and the provider and member agree to proceed, obtain written informed consent from the member acknowledging responsibility for payment.

Definitions and Background

Scintimammography is a nuclear medicine technique that images the breast after intravenous administration of a radiopharmaceutical, most commonly technetium Tc‑99m sestamibi. Imaging may be performed with conventional planar gamma cameras or with dedicated breast‑specific gamma cameras (BSGI/MBI) that position detectors close to the breast to improve spatial resolution.

Breast‑specific gamma imaging or molecular breast imaging uses dedicated detectors (multi‑crystal arrays or semiconductor detectors) and specialized positioning; typical MBI examinations require approximately 40 minutes. Evidence reports variable diagnostic performance (for example, negative predictive values in the range of about 83%–94%), and overall the literature does not demonstrate sufficient accuracy or outcome benefit to replace standard diagnostic pathways such as diagnostic mammography, spot views, ultrasound, or MRI.

BSGI / MBI definitions — dedicated breast gamma camera types and detector descriptions

DefinitionBreast‑Specific Gamma Imaging (BSGI) and Molecular Breast Imaging (MBI): dedicated scintimammography using breast‑specific gamma cameras with detectors positioned close to the breast to increase resolution

Detector typesMulti-crystal arrays of cesium iodide or sodium iodide (BSGI) and semiconductor detectors such as cadmium zinc telluride (MBI)

Positioning