Highmark Medicare Advantage Medical Policy in West Virginia

Section:	CMS National Guidelines
Number:	N-159
Topic:	Percutaneous Image-Guided Breast Biopsy - NCD 220.13
Effective Date:	March 9, 2009
Issued Date:	March 9, 2009

General Policy

Percutaneous image-guided breast biopsy is a method of obtaining a breast biopsy through a percutaneous incision by employing image guidance systems. Image guidance systems may be either ultrasound or stereotactic.

Indications and Limitations of Coverage

The Breast Imaging Reporting and Data System (BIRADS) employed by the American College of Radiology provides a standardized lexicon with which radiologists may report their interpretation of a mammogram. The BIRADS grading of mammograms is as follows: Grade I-Negative, Grade II-Benign finding, Grade III-Probably benign, Grade IV-Suspicious abnormality, and Grade V-Highly suggestive of malignant neoplasm.

Nonpalpable Breast Lesions
Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for a radiographic abnormality that is nonpalpable and is graded as a BIRADS III, IV, or V.

Palpable Breast Lesions
Percutaneous image guided breast biopsies are covered using stereotactic or ultrasound imaging for palpable lesions that are difficult to biopsy using palpation alone. The Plan has the discretion to decide what types of palpable lesions are difficult to biopsy using palpation.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

77031

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-3, NCD 220.13

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.