Evicore Breast Imaging Guidelines

CLINICAL GUIDELINES Breast Imaging Guidelines Version 1.0 Effective January 1, 2021

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 2020 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 V1.0

Breast Imaging Guidelines Abbreviations for Breast Guidelines 3 BR-Preface1: General Considerations 5 BR-1: Breast Ultrasound 8 BR-2: MRI Breast 10 BR-3: Breast Reconstruction 12 BR-4: MRI Breast is NOT Indicated 13 BR-5: MRI Breast Indications 14 BR-6: Nipple Discharge/Galactorrhea 18 BR-7: Breast Pain (Mastodynia) 19 BR-8: Alternative Breast Imaging Approaches 20 BR-9: Suspected Breast Cancer in Males 21 BR-10: Evaluation in Pregnant or Lactating Women 22

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Breast Imaging Breast Imaging Guidelines V1.0

BR-Preface1: General Considerations BR-Preface1.0: General Guidelines 6 BR-Preface1.1: BI-RADS™ Categories Chart 6 BR-Preface1.2: BI-RADS™ Breast Density Categories 7

______©2020 eviCore healthcare. All Rights Reserved. Page 5 of 26 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com  0 ukatrPaeBuead lftn C290(0)918- 29910 (800) SC Bluffton, Place Boulevard, 400 Buckwalter ______BR-  BR- Breast ©2020 Category 1: Negative Category 0: Incomplete Category Suggested Follow Interval – Finding Benign 3: Probably Category 2: BenignCategory Finding Current clinical evaluation is not required prior to screening studies. advanced imaging. A current clinical evaluation (within 60 days) is usually required prior to considering Preface1.1 .0 Preface1

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