Scintimammography, BSGI, and MBI Medical Necessity Policy
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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.
No material changes — policy has no listed updates in this brief.
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.
Key points: • HCPCS code explicitly listed as not medically necessary: 1 • Medically necessary exception noted: Sentinel lymph node localization exception • Medical criteria specified: None
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
Exception (provider guidance): Gamma detection following radiopharmaceutical administration for localization of sentinel lymph nodes in patients with breast cancer may be considered medically necessary.
Codes — Not Medically Necessary
| S8080 | Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical |
Provider Actions
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.
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. |
Revision History
Policy effective date
Policy last updated
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