MRI of the breast is considered eligible for patients for the following indications:

• Patients with a known BRCA1 or BRCA2 genetic mutation;
• Patients who are at high risk of BRCA1 or BRCA2 genetic mutation due to a known presence of the mutation in relatives;
• Patients with a history of breast cancer 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;
• Patients who have a personal history of malignant neoplasm of the breast for the presence or recurrence of breast cancer or for additional lesions following a diagnosis and/or treatment of breast cancer in male or female patients;
• To evaluate the contralateral breast in those patients with a new diagnosis of breast cancer who have normal clinical and mammographic finding in the contralateral breast;
• Preoperative mapping of the involved (ipsilateral) breast to evaluate the presence of multicentric disease in patients with clinically localized breast cancer who are candidates for breast-conservation therapy;
• To determine the presence of breast cancer or for additional lesions following a diagnosis and/or treatment of breast cancer in male or female patients. Examples include but are not limited to: very dense breast tissue, mammographic microcalcification, dysplasia or severe fibrocystic changes, infiltrating lobular or ductal carcinoma, presence of pectoralis major muscle/chest wall invasion in patients with a posteriorly located tumor, or carcinoma invasion deep to fascia;
• To determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumor;
• To detect suspected occult breast primary tumor in patients with axillary nodal adenocarcinoma (for example, negative mammography and physical examination);
• For presurgical planning in patients with locally advanced breast cancer before, during and/or after completion of neoadjuvant chemotherapy (for example, to permit tumor localization and characterization, evaluate chemotherapeutic response and/or residual disease prior to surgery);
• To detect a rupture of silicone or non-silicone breast augmentation or implant(s).

NOTE:

It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in the following situations.

• Patients 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;
• Patients who have received radiation therapy to the chest between the ages of 10 and 30 years of age.

Covered diagnosis codes for the above indications include: 174.0-174.9, 175.0-175.9, 198.81, 233.0, 238.3, 239.3, 610.2, 611.72, 611.79, 611.82-611.89, 612.0-612.1, 759.6, 785.6, 793.80, 793.81, 793.89, 793.99, 996.54, V10.3, V16.3, V84.01, V43.82.

MRI studies of the breast for all other indications are considered experimental/investigational. Scientific evidence does not demonstrate that MRI of the breast impacts or improves health outcomes. Additional studies are needed to evaluate the intermediate and long-term outcomes for findings observed only on MR imaging. Lesions shown to be breast cancer seen only on MR imaging may have different clinical characteristics than cancer identified by physical examination and/or other imaging techniques. These characteristics will help to determine if important changes in clinical management are necessary to improve outcomes. A participating, preferred, or network provider can bill the member for services denied as experimental/investigational.

Date Last Reviewed: 02/2008

Payment is made for paramagnetic contrast material (codes A9576-A9579, Q9951, Q9953, Q9954, Q9957-Q9967, as appropriate) in addition to the MRI procedure. The diagnostic imaging agent/contrast material used in conjunction with an eligible imaging procedure is eligible when administered by the health care professional in a setting other than a hospital or a skilled facility.

When charges for additional acquisitions, cuts, slices, etc., are billed separately, the charges are combined and paid under the appropriate code for the study performed.

When both MRI and a computed tomography (CT) scan are performed on the same day for the same anatomic area, payment should be made for the CT scan. The MRI may only be paid if supporting documentation is submitted to establish medical necessity for both studies.

Computer Aided Detection (CAD) with MRI of the Breast (Code 0159T)
Computer-aided detection (CAD), including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation for MRI of the breast (code 0159T) is considered experimental/investigational for all indications and uses. There is insufficient scientific evidence to support its clinical use outside the investigational setting. Additional data from clinical trials are also needed to determine whether CAD performed in conjunction with MRI of the breast improves the intermediate and long-term patient health outcomes. When reported, this procedure will be denied as experimental/investigational. A participating, preferred, or network provider can bill the member for a service denied as investigational.

Date Last Reviewed: 01/2007

Description

Magnetic resonance imaging, also referred to as nuclear magnetic resonance (NMR), is a noninvasive diagnostic imaging modality. The technique uses the interaction of a magnetic field and radiofrequency waves to generate, with computer assistance, an image of an area of the body.

For additional information on MRI see Medical Policy Bulletin X-2.

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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography, A Cancer Journal for Clinicians, Vol. 57, No. 2, Mar/Apr 2007* (*In January, 2008 the ACS noted that the information in this article remains current.)

Practice Guidelines for the Performance of MRI of the Breast, American College of Radiology (ACR), 2006

MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer, The New England Journal of Medicine, Vol. 356, No. 13, Mar 2007

Imaging Breast Cancer, Radiologic Clinics of North America, Vol. 45, 2007

Diagnostic Breast MR Imaging: Current Status and Future Directions, Radiologic Clinics of North America, Vol 45, 2007

MRI for Diagnosis of Pure Ductal Carcinoma In Situ: A Prospective Observational Study, The Lancet, Vol. 370, Aug 2007

Screening and Follow-up of the Patient at High Risk for Breast Cancer, Obstetrics & Gynecology, Vol. 110, Dec 2007

Breast MRI lesion classification: Improved performance of human readers with a backpropagation neural network computer-aided diagnosis (CAD) system, Journal of Magnetic Resonance Imaging, Vol. 25, No. 1, January 2007

Role of MRI in screening women at high risk for breast cancer, Journal of Magnetic Resonance Imaging, Vol. 24, No. 5, November 2006

Patterns of enhancement on breast MR imaging: interpretation and imaging pitfalls, Radiographics, Vol. 26, No. 6, November-December 2006

Magnetic resonance imaging captures the biology of ductal carcinoma in situ, Journal of Clinical Oncology, Vol. 24, No. 28, October 2006

The efficacy of breast MRI in predicting breast conservation therapy, Journal of Surgical Oncology, Vol. 94, No. 3, September 2006

Computer-aided detection and diagnosis of breast cancer, Seminars in Ultrasound, CT, and MR, Vol 27, No. 4, August 2006

Screening MRI for women at high risk for breast cancer, Seminars in Ultrasound, CT, and MR, Vol. 27, No. 4, August 2006

Computer-aided Detection Applied to Breast MRI: Assessment of CAD-generated Enhancemnet and Tumor Sizes in Breast Cancers Before and After Neoadjuvant Chemotherapy, Academic Radiology, July 2005

Computer Aided Detection (CAD) for Breast MRI, Technology in Cancer Research and Treatment, February 2005

Magnetic Resonance Imaging of the Breast Prior to Biopsy, Journal of the American Medical Association, Vol. 292, No. 22, December 2004

Surveillance of BRCA1 and BRCA2 Mutation Carriers with Magnetic Resonance Imaging, Ultrasound, Mammography, and Clinical Breast Examination, Journal of the American Medical Society, Vol. 22, No. 11, September 2004

Efficacy of MRI and Mammography for Breast-Cancer Screening in Women with a Familial or Genetic Predisposition, The New England Journal of Medicine, Vol. 351, No. 5, July 2004

Breast Cancer Screening with MRI – What Are the Data for Patients at High Risk? – An Editorial, The New England Journal of Medicine, Vol. 351., No. 5, September 2004

National Blue Cross Blue Shield Medical Policy 6.01.29

Magnetic Resonance Imaging of the Breast for Preoperative Evaluation in Patients with Localized Breast Cancer, National Blue Cross Blue Shield TEC Assessment, September 2004

Breast MRI for Management of Patients with Locally Advanced Breast Cancer Who Are Being Referred for Neoadjuvant Chemotherapy, National Blue Cross Blue Shield TEC Assessment, September 2004

American Society of Breast Disease Policy Statement: The Use of Magnetic Resonance Imaging of the Breast (MRIB) for Screening of Women at High Risk of Breast Cancer, June 2004

Website of the National Cancer Institute