Evicore Breast Imaging

CLINICAL GUIDELINES Breast Imaging Policy Version 1.0 Effective February 14, 2020

eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’s Primary Care Physician (PCP) may provide additional insight.

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

Breast Imaging Guidelines Abbreviations for Breast Guidelines 3 BI-RADS™ Categories Chart 5 BR-1: Breast Ultrasound 7 BR-2: MRI Breast 8 BR-3: Breast Reconstruction 10 BR-4: MRI Breast is NOT Indicated 11 BR-5: MRI Breast Indications 12 BR-6: Nipple Discharge/Galactorrhea 15 BR-7: Breast Pain (Mastodynia) 16 BR-8: Alternative Breast Imaging Approaches 17 BR-9: Suspected Breast Cancer in Males 18

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