CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Scintimammography, BSGI, and MBI Medical Necessity Policy

Defines medical necessity and coverage stance for scintimammography, breast-specific gamma imaging (BSGI), and molecular breast imaging (MBI) for BlueCHiP for Medicare and Commercial products, including use as adjunct to mammography and staging of axillary lymph nodes, and notes on gamma detection for sentinel lymph node localization.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyScintimammography, BSGI, and MBI Medical Necessity Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 17, 2017

Next Review Date

Key ActionVerify member-specific benefits and eligibility in the Evidence of Coverage, Subscriber Agreement, or Benefit Booklet because benefits may vary between groups/contracts.

SourceLink

POLICY UPDATE CHANGES

No material changes — policy has no listed updates in this brief.

1HCPCS code explicitly listed as not medically necessary

Sentinel LN localizationMedically necessary exception noted

NoneMedical criteria specified

Coverage Summary

Overview: Scintimammography, breast-specific gamma imaging (BSGI), and molecular breast imaging (MBI) are considered not medically necessary in all applications (including use as an adjunct to mammography and staging of the axillary lymph nodes) except for a specified exception. Exception: gamma detection following radiopharmaceutical administration for localization of sentinel lymph nodes in patients with breast cancer may be considered medically necessary.

Medical Necessity Criteria

Coverage Determination

Scintimammography, BSGI, and MBI coverage determination:

ALL of the following

Not medically necessary in all applications
- Use as an adjunct to mammography
- Staging the axillary lymph nodes
- Other applications (including but not limited to the above) as evidence is insufficient to determine effects on health outcomes
Exception: Use of gamma detection following radiopharmaceutical administration for localization of sentinel lymph nodes in patients with breast cancer may be considered medically necessary

ref": "b1_0

title": "Coverage Determination

Exception (provider guidance): Gamma detection following radiopharmaceutical administration for localization of sentinel lymph nodes in patients with breast cancer may be considered medically necessary.

Provider Actions

Documentation Required

Benefit verification

Verify member-specific benefits and eligibility in the Evidence of Coverage, Subscriber Agreement, or Benefit Booklet because benefits may vary between groups/contracts.

Billing Rule

Sentinel lymph node localization coverage

Gamma detection following radiopharmaceutical administration for localization of sentinel lymph nodes in patients with breast cancer may be considered medically necessary; document the clinical indication and the procedure for potential coverage.

Operational note: Verify member-specific benefits and eligibility in the Evidence of Coverage, Subscriber Agreement, or Benefit Booklet because benefits may vary between groups/contracts. When submitting claims for sentinel lymph node localization using radiopharmaceuticals and gamma detection, document the clinical indication and the procedure to support potential coverage.

Background

Background: Scintimammography uses radiopharmaceuticals with nuclear medicine imaging to detect breast tumors; after injection, planar imaging of the breast is performed. Conventional gamma cameras have relatively poor resolution for small lesions (e.g., <15 mm). BSGI and MBI use breast-specific gamma cameras or molecular breast imaging systems with detectors placed close to and sometimes compressing the breast to increase resolution and improve diagnostic performance. The radiotracer usually utilized is technetium Tc99m sestamibi. Preoperative lymphoscintigraphy and intraoperative hand-held gamma detection after radiotracer injection are used to identify sentinel lymph nodes for biopsy as an alternative to full axillary lymph node dissection for staging and management of breast cancer.

Definitions: Scintimammography — use of radiotracers with nuclear medicine imaging as a diagnostic tool for breast abnormalities. BSGI / MBI — breast-specific gamma imaging or molecular breast imaging: specialized imaging machines used with scintimammography to improve diagnostic performance by placing detectors close to the breast.

Evidence summary: Diagnostic accuracy studies, systematic reviews, meta-analyses, and observational studies exist for BSGI/MBI and scintimammography, but the evidence is insufficient to demonstrate improved health outcomes for most uses; therefore these technologies are considered not medically necessary in most applications.

Definitions

Term	Definition
Scintimammography
Use of radiotracers with nuclear medicine imaging as a diagnostic tool for abnormalities of the breast.
BSGI / MBI
Breast-specific gamma imaging (BSGI), or molecular breast imaging (MBI), refers to specific types of imaging machines that are used in conjunction with scintimammography to improve diagnostic performance by placing detectors close to the breast.