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.

© 2019 eviCore healthcare. All rights reserved. Breast Imaging Guidelines V1.0

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 19

______©2019 eviCore healthcare. All Rights Reserved. Page 2 of 22 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Breast © 2019 BI GERD COPD HRCT LFTP DCIS MRA LCIS EMG AVM MRV ECG CAD - AAA FDG ACE CTA CTV MRI IPF RADS BP CT

GI Imaging eviCore healthcare eviCore

Guidelines magnetic magnetic magnetic localized lobular idiopathic high gastrointestinal gastroesophageal fluorodeoxyglucose electromyogram electrocardiogram ductal computed computed computed chronic computer blood Breast arteriovenous angiotensin abdominal Abbreviations

resolution

pressure

carcinoma

Imaging

carcinoma obstructive . All All .

fibrous -

resonance resonance resonance

pulmonary aided

tomography tomography tomography aortic - Rights Reserved. Rights converting

malformation

computed

Reporting

detection

tumor

aneurysm in

in reflux

pulmonary situ

situ venography imaging angiography fibrosis

venography angiography of enzyme

disease for

the tomography and

pleura

Breast disease Database

8924 8924 BRCA CBC FNA FDA

DVT

EM System Guidelines

Complete tumor fine Administration Food electromagnetic deep

needle

venous

and suppressor

Drug blood www.eviCore.com

aspiration

thrombosis

Page 3of22

count

gene V1.0

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Breast © 2019 RODEO PEM NCV SVC SPN PPD PET PFT PE

Imaging eviCore healthcare eviCore

Guidelines superior solitary Rotating purified pulmonary positron positron pulmonary nerve

conduction

pulmonary . All All . protein -

emission vena emission Delivery

function embolus Rights Reserved. Rights

cava

derivative

of velocity tomography

mammography nodule

tests Excitation

of

tuberculin

Off

- resonance

8924 8924

MRI

www.eviCore.com Page 4of22 V1.0

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Breast © 2019 These Taken Category treated These Taken Category the concern but There Category followed. validity intuitive. efficacy prefer It A Category malignancy. implants, confidence. hamartomas containing finding. This Category architectural There Category Need Category is finding

Imaging patient have a eviCore healthcare eviCore not

is

additional

are to is

lesions lesions

also

of surgically Involuting, expected

of

to

nothing

These establish placed

etc.

an

0: 6: 5: 4: 3: 2: 1: lesions

short Guidelines lesions urge and definite a

The

) disturbances, Incomplete Known Highly Suspicious Probably Benign Negative approach,

negative

while all have have a

her a a

will

imaging interval in interpreter have to

to ( that biopsy.

its

calcified

this probability such comment physiciancan likely

. All All . still

BI been change Suggestive

Biopsy Finding stability.

high characteristic

do

mammogram, category - Rights Reserved. Rights Ben concluding

the

RADS™ follow

as evaluation

undergo

not Abnormality biopsied If

probability or

might ign fibroadenomas, interval cysts, oil possible, over

-

on.

have Proven

suspicious of - Data up. – Finding

should being

The

of the make wish

future

At and r the that

is or Malignancy equired, appearances,

lipomas, follow

the the but breasts Categories Malignancy– of

becoming

prior

malign characteristic

to – are

there

have a

the

being

modification

calcifications relevant present the Biopsy describe Short

-

known

up mammograms decision multiple

interpreter and is ant.

are

galactoceles, cancer interval,

very no

available -

Interval

Appropriate

time, the symmetrical Should The possibilities

to and mammo intramammary 8924 8924

high

secretory Appropriate morphologies on

be as type

and are

radiologist

most may Chart

but

the malignant may more

probability Follow

Be that

of present. should

for graphic

the

ultimate

be and

approaches findings

wish

Considered

comparison. should accrue data calcifi and

sheds Action radiologist labeled

mixed

-

has

up

be lymph .

to Action

no masses, evidence of

cations,

of course

describe a

biopsied Suggested

light that be breast sufficient

Should www.eviCore.com

being with density

nodes, cited

are

should Should on would

as Page 5of22

of

fat cancer of benign. the

so so

to or action.

Be

V1.0

the

be that

Be

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Breast © 2019 Category Category Category Category

Imaging eviCore healthcare eviCore D: C: B: A Guidelines :

BI Extremely Heterogeneously Scattered Almost - RADS™ . All All .

entire Rights Reserved. Rights

fibroglandular dense

fatty

Breast

dense

densites

Density

8924 8924

Categories www.eviCore.com

Page 6of22 V1.0

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______     Breast    © 2019 Ultrasound US Ax especially limited) Breast Routine biopsy scre State Specific Density Reporting and Imaging Mandate Laws nonspecific, any nipple Palpable BI omen epeat epeat linical

- Imaging illa eviCore healthcare eviCore RADS

 Equivocal U Breast Bilateral For If If A  ultrasound abnormality not density individuals months imaging, nodes should involving The

guided Additional ening order,

ltrasound r r

c ultrasound

inversion) See CPT Radiologist MRI ultrasound to indicated

w

can pertinent performance

™ breast . document Guidelines

Link: 3

mammography density in

be assessed

regardless

breast notification ® Breast from CH- Breast

Cat

s be

imaging imaging which equivocal members 76442) office differentiating

hould or

risk l with

s

esions with used 2.2: Axillary2.2: Lymphadenopathy 3 State has

creening . masses Occult Occult

the

1,2,3 should (CPT language

biopsy ultrasound

notification (CPT . All All . Report a a

profile. can may visit

be successful successful

clinically been

date and is remains to FNA

of S of BR-

Rights Reserved. Rights

should

® BI-R coded laws

or

in be

pecific Mandates further is Findings: ® include

as 76882)

breast

be age.

or

inconclusive

76641: (CPT these for of uncertain.

identified not recommendation is repeated or

cysts

benign

in other evaluated ADS

vary, 1: the

suspi inappropriate. women BI-R biopsy

follow CPT necessary be Ultrasound these laws

® evaluate

ultrasound lesion states, Breast

initial MRI

19083) ™ 1 1 ™

billed unilateral, from clinical but ® ADS cious

(Cat have

on can can 76882x 2 at up

mandates

and/or whose or some

imaging.

or

sampling with solid

least recent using ™

their imaging

2).

2, abnormalities

includes lymph help prior been conflicting abnormalities can

3,

16

1,2,3 then Ultrasound as

mammography

6

complete also lesions for

ultrasound.

only legislative

repeat CPT

identify stand- enhance (withi months to

put

is

After Breast nodes, imaging for

if

contain breast

indication provided

the ®

histology in the Chest Imaging Guidelines 8924 8924 into

.

n n stable 19084. 1 findings at 2 2 alone

the imaging

OR

patients

after

12

found ultrasound years

(such effect mandates preoperative

biopsy

ultrasound

For

reverts mandates

last

months, CPT

findings

screening via

and an is

is

applicable

on

on of

by 60

as

dense

component. benign . the ® who 3 US

stability,

mammography breast

76642: mammogram, skin to many days)

should

(CPT

link 18 directed

at routine

when have for

axillary

6 breast

or change, months, and

states. states.

www.eviCore.com

below. ultrasound, mammogram. additional

months requests

® unilateral,

with

the

76441 positive be an Page 7of22 per

tissue breast

finding followed.

Breast pain, and

or V1.0 or

is in

24

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ MR       Breast   © 2019 pharmacokinetic analysis), when performed; bilateral CPT Although document MRI MRI the use of (CPT 770 preferred Magnetic most computer Magnetic resonance imaging, breast, without and with contrast material(s), including pharmacokinetic algorithm The The mammogram malignancies, equivocal unnecessary integrity increase Magnetic resonance imaging, breast, without contrast material; bilateral (CPT pharmacokinetic computer Computer malignant I

Breast dditional ince he he

Imaging eviCore healthcare eviCore A HCPCS CPT S T T with MRI interpretation. investigational, 47) or Magnetic resonance imaging, breast, without contrast material; unilateral

® use use Breast guided ® individuals 77048

7704

B

® use use further

– in of of

with

- 76377 -

MRI reast the Guidelines resonance

in successful successful analysis - or aided detection (CAD real aided

varies gadolinium contrast.

aided Practice asymptomatic,

gadolinium gadolinium

code can 6) 6)

breast of of some

uncertain.

procedures.

with CAD

younger and lesions

Breast it

maybe performed HCPCS CAD

physician data

be carries detection should

for detection from analysis, analysis), 9

C8937

these ultrasound.

individuals

. All All .

of

software experimental, biopsy repeated

the has Notes for

imaging, MRI has should

lesion

Rights Reserved. Rights 3%

age 5 contrast contrast a a

code lesion not

evaluation

procedures. little

review B

The significant

superior

average- (CAD to (CPT . .

with

(CAD)

when

be reast The BR- automatically

sampling

20% C8937 be

at influence use after

breast, detection/ch Incidental

used

further least ® is is

billed percentag real for

19085) data and/or

performed; is 2: if there are clinical reasons or concerns regarding not depending required

of sensitivity mas of risk

interpretation) included - - in (CAD false 6 6

time lesion detection, characterization and time HCPCS

breast MRI

necessary physician physician without

if using

for conjunction

months on tectomy,

patients.

histology

unproven. lesions includes

lesion positive

lesion performs the including e e aracterization, for

Breast CPT parenchyma. of

with unilateral

in on

code and sensitivity the

a incidental

identifying

fter detection/characterization, per are the detection, review for ®

is

the

the 8924 8924 evaluation risk with 19086. is

with

C8937

3D

benign computer the

patient an physician seen currently

MRI

(CPT imaging

when

contrast (CPT

imaging, MRI CPT

for evaluation specificityand

lesions

pharmacokinetic B

on

new

(CAD ® characterization

interpretation) and

population. reast ® directed ® compared

77049 of 15%

77049,

77048 considered algorithm component. request.

unknown breast material(s), nonspecific,

CPT including that

CPT

of ) of )

is

MRI breast ® CPT turn implant may www.eviCore.com

® 76376 preferred parenchyma.

to of Cancer

77049 analysis B

®

is Page 8of22 MRI out

computer be analysis,

reast

77048 including and biopsy

or to ®

B and

V1.0 is

reast

be in

and of

or

to

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Breast © 2019 identified lesions

Imaging eviCore healthcare eviCore ”. 6,7 by Guidelines

MRI

Breast . All All .

Rights Reserved. Rights

in

only

0.7%

of

those

with 8924 8924

“inconclusive mammographic www.eviCore.com Page 9of22 V1.0

Breast Imaging Breast Imaging Guidelines V1.0

BR-3: Breast Reconstruction  CTA or MRA of the body part from which the free tissue transfer flap is being taken, can be performed for breast reconstruction preoperative planning.2,3 For example, CTA Abdomen and/or Pelvis (CPT® 74175 or CPT® 72191 or CPT® 74174) or MRA Abdomen and/or Pelvis (CPT® 74185 and/or CPT®.72198) for Deep Inferior Epigastric Perforators (DIEP) flap.8  There is currently insufficient evidence-based data to support the need for routine advanced imaging for TRAM flaps or other flaps performed on a vascular pedicle.8 Imaging Breast

______©2019 eviCore healthcare. All Rights Reserved. Page 10 of 22 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com Breast Imaging Guidelines V1.0

BR-4: MRI Breast is NOT Indicated  MRI Breast should not be used to determine biopsy recommendations for suspicious or indeterminate lesion(s) that can be readily biopsied, either using imaging guidance or physical exam, such as palpable masses and microcalcifications.3,6  Patients with dense breasts as determined by mammogram To date, evidence does not suggest improved outcomes for women whose only risk factor is breast density [See heading “Equivocal or Occult Findings” (Radiologist Report) in BR-5: MRI Breast Indications].13,14,15  Low risk, probably benign (BI-RADS™ 3) lesions Repeat the original type study (mammogram, US, or MRI) in 6 months  If repeat imaging remains BI-RADS™ 3, repeat original study at 12 months, 18 months, and 24 months from the date of the initial imaging. After 2 years of stability, the finding should be assessed as benign (Cat 2).16  If repeat imaging is BI-RADS™ 1 or 2, then imaging reverts to routine per individuals risk profile.

 Suspicious (BI-RADS™ 4 or 5) lesion on mammogram and/or ultrasound. A lesion categorized as have BI-RADS™ 4 or 5 should be biopsied.16

 Surveillance MRI for silent/asymptomatic rupture of silicone implants is considered investigational, as there is no evidence basis that surveillance reduces morbidity and/or mortality. However, certain payers may cover this surveillance and those coverage policies take precedence over eviCore guidelines.17,18 Certain payers do not include breast implants in their coverage policies if the breast implants were placed as part of purely cosmetic surgery. Thus, surveillance MRI in these patients would also not be included in the coverage policy. Their coverage policies will take precedence over eviCore’ guidelines.

 Routine surveillance MRI Breast following mastectomy is not indicated45 Imaging Breast

______©2019 eviCore healthcare. All Rights Reserved. Page 11 of 22 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______       Breast  © 2019 Indications Res Ne Ne Eq P MRI guidelines) breast MRI document equivocal hyllodes obably reast

Imaging eviCore healthcare eviCore uivocal wly wly  in with MRI Evaluate breasts, mammography Evaluate Assessment  A Radiologist mastectomy. have close uninterpretable. change conflicting tissue diagnosis discrete discrete idual

Breast Breast 6 6 pr

Diagnosed Diagnosed If If 24 individuals finding reconstruction,

months physical B repeat repeat

or

Guidelines

months diagnosis successful successful or or Tumor

.

for

in 26,28 is palpable can reconstructed Recurrent

Occult Occult uncertain. c or

of surgical linical findings

should

indicated

annual benign

or

R is co

imaging imaging malignant

29 be of examination eport

(Cystosarcoma

positive indicated nfirm from risk Breast Paget’s

. All All .

BR-5:

r and/or 1 repeated . esidual

Findings 18,19,20 suspicion mass. be

lesion

MRI profile. Rights Reserved. Rights management lesion free

on Malignancy Recommendation 5

the

breast

for assessed remains is

Cancer

mammography margins,

BI-R

ultrasound, B

breasts, (S Disease phyllodes

date injection,

breast preoperatively tumor MRI sampling reast ee on

at or

of implant

ADS

least

Practice of MRI

BI-R other 4 recurrence,

Phyllodes)

in

(including screening augmentation,

the 5 as Breast and when

.

™ 1 1 ™

(thereafter

29 patients 6 6 and (MRI tumor

ADS

benign

if if clinical initial rupture months

possible those histology

or Note)

capsular for the or

to ™ BI

2, has

S

ultrasound imaging.

DCIS) MRI

-

establish who following findings

3,

RADS (Cat

indicators. then Indications evaluations ee when

after

treat previously repeat

chest

Breast breast table is

have 8924 8924

contracture 2). . imaging

1,6,24,25,26

TM benign

an mammography as

16 After may

3) 3)

extent evaluations

wall at

below: undergone MRI of DCIS

implants and

This should 12 a a

are 2 indicate been

recurrences and reverts

finding directed inconclusive months,

years

of

according applies inconclusive to:

nonspecific, disease established undergo

(saline

a a

with lumpectomy of to that

or

significant

breast

18 to www.eviCore.com stability, routine

ultrasound

is

following

intact to where a months,

or Page 12of22 repeat

or not

these

or

silicone), biopsy

by a

per

conflict the

V1.0

and MRI

and

is

to

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Breast © MRI MRI MRI High with MRI 2019 1 1 10. 6 9 8 7 5 4 3 2. 1. 2 1......

breast screening screening screening screening

Imaging eviCore healthcare eviCore Risk Clinical with A cancer One 50. One Two then been First additional The ATM, PTEN age BRCA Patient whichever starting Li clinical

- first Fraumeni

cancer

- 25 following breast Indications or first first ann degree

tested

CHEK2, Guidelines

or Mutation

. 1

s

of BARD1, Lobular Atypical Atypical risk unknown

more lifetime begins to to to

at

- - or with ual second

degree degree

intermediate

MRI begin begin begin age comes

, BRCA estimator cancer

but for screening

Syndrome relative first a have

NBN

20

screening at

history

carcinoma risk BRCA . All All .

lobular ductal (Cowden not MSH2, - at at at relative relative -

significance, degree

age degree

first or . 2

age diagnosis age

unknown , Rights Reserved. Rights prior estimated

begin (parent, at

Peutz

such .

40,

hyperplasia

of . mutation

is penetrance.

the hyperplasia determined 20: (TP53 MLH1,

male with with to

not :

relatives is Syndrome

or

age

- in

as age

Jehgers the not

10

indicated situ or sibling, but

bilateral breast

Gail, genetic

at relative M mutation)

40

age of indicated years insufficient

(If greater SH6, not (LCIS)

the with

(ADH) 41

Claus, patient by

(ALH) of

), Syndrome

cancer

prior child)

earliest

before

. CDH1, variants breast 25 (father, gene

PMS2, ) breast

21 should than

:

at

4,12,22,30,42,43

to

Tyrer

has with

evidence

this

or mutation

age

the

cancer,

NF1, or diagnosed

EPCAM,

brother, or

ovarian favoring

been (STK11,

- BRCA

start time:

equal Cuzick age ovarian 25 8924 8924

PALB2 :

tested : annual

of of or

to 1 uncle cancer

RAD51C,

polymorphism, breast relative

or both LKB1

or cancer breast 20%

BRCAPRO begin BRCA and

,

breast

breast grandfather

that gene using cancer

when . cancer negative

age

Genetic

2, was

screening

and variations)

genetic if

30 first

risk

models patient

genetic www.eviCore.com diagnosed in

ovarian

)

for

the diagnosed and variants diagnosed Page 13of22

risk mutation

family, . MRI has

variants

begin

or V1.0

not ≤

of age

Breast Imaging  - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ MRI Breast  © Personal Additional 2019 1 1 1 1 6 5 4 3 S M s M Phyllodes

. . . . onographically suspicious Breast

tate SpecificDensityReportingandImagingM reatment gnosis hyllodes reast RI shouldnotbeusedinlieuofmammographically,c andates)

Imaging eviCore healthcare eviCore Guidelines Sarcomas– phyllodes), If T Dia fibroadenoma, P density B It biopsy). shown imaging, involving recommended. The breast MRI breast MRI breast breast MRI first screening Women estimated such

biopsy has

. H

pertinent 4,12,30

Breast Breast Breast a a R Indications as istory Guidelines

Tumor cancer. cancer cancer cancer density

to isks: notification

predilection

with the FNA

establishes

which members be

should at

tumor is ).

is

it surveillance surveillance surveillance Gail,

18,19,20

of greater history

made of

wide

Bone, should

(CystosarcomaP biopsy (not 11,12 diagnosed and language

notification

although . All All .

B value may

Claus, is start reast

-

extremely

treated

local

Rights Reserved. Rights

usually by

laws of in Practice

than

for

Soft a a include be is 8

in tissue radiation these

diagnosis

C

inaccurate (annual) (annual) (annual) Tyrer

to

loc findings(ACRPractice treated excision. distinguishing

in before or they vary,

ancer with

Tissue 10

these laws al benign equal

dense

- states,

MRI

years

diagnosis

Cuzick recurrence Notes may bilateral

but to age

is is is as have hyllodes)

to

mandates the

of

and and/or Axillary indicated indicated indicated

breast some a a

post and exhibit in 50.

20%

their

or malignant

chest soft

phyllodes been mastectomy)

39

GIST BRCAPRO fibroadenoma -

has therapy,

(percutaneous

tissue using

also

ultrasound. following legislative

tissue

lymph rapid between

for for for

put clinical

is in

contain

andate Laws(L genetic provided patients patients patients

the phyllodes (Category

8924 8924 into sarcoma ( sarcoma tumor or growth.

Guidelines). node dissection

models

at

who local Oncology ages

characteristics effect mandates

age linically, and/or

For risk from

mandates with with with diagnosis

core a had

via excision.

10 Breast

(cystosarcoma (cystosarcoma 25, D) applicable or prior

by

See

a a a

phyllodes

and the

on

clinical

biopsy whichever personal personal personal

clinical Imaging many

ink

to

mammography

should

- ONC link 30; MRI

initial for toState Specific and

is

risk of breast states. states.

www.eviCore.com

above . or additional not

lifetime

requests has

12: history history history is tumor.

diagnosis

excisional be comes Page 14of22 estimator

not necessary.

not followed.

Breast risk

of of of

been V1.0 .

39

of

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ N     Breast © 2019 ipple prol For and and If unilateral, Mammogram Physiologic Pathologic determined commonly single colors hyperprolactinemia

nipple

Imaging eviCore healthcare eviCore If If

technically

actinoma; milky Discharge/Galactorrhea- the mammogram

mammogram the

duct, including

patient

discharge nipple

Guidelines discharge,

limited)

- multi nipple

by nipple persistent, BR-6:

and pituitary results. limited,

can discharge serous, duct.

discharge

and should ultrasound . All All .

discharge is and

can be

prolactin physiologic,

Nipple It

Rights Reserved. Rights 31,32,33,34 MRI

imaging ultrasound reassured. and

ultrasound

is be yellow,

be is predominantly B

considered spontaneous.

is pathologic, reast obtained is (CPT

and defined

is predominantly Practice

green, Discharge/Galactorrhea

not there 31,32,33,34

are can TSH are ® 76641:

needed negative,

as

(S as be negative, brown,

are levels ductography

milky,

Notes ee initial unilateral, performed.

no

unilateral, Practice

if

suspicious suspicious are bilateral, or

imaging,

normal but

no

and gray.

8924 8924 recommended

additional may

bloody

31,32,33,34 ductography should Note

complete Evaluation serum

but be with findings

). white may or 31,32

be

clinical

imaging serous, serous, Prolactin.

attempted.

be or 33,34

to or

for is on

CPT

a unilateral. diagnose

pathway unavailable

www.eviCore.com clinical variety is arising

® necessary, Page 15of22 76642:

exam,

of

from It V1.0

is or a

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______   Breast © Breast Pain– 2019 The CPT Adv Mammogram exam, negative pregnancy

Imaging eviCore healthcare eviCore If evaluationisnotnegative,Se anced

® risk 76642:

mammogram,

of evaluation Guidelines

imaging malignancy test, P

ractice Notes

unilateral, and mammogram BR-7:

ultrasound . All All .

is (evaluation

ultrasound) NOT Rights Reserved. Rights

following

limited) Breast

routinely

are and . includes 39 a a

has the

ultrasound negative e BR-5:

indicated

Pain initial been

patient imaging estimated MRI BreastIndications clinical

(Mastodynia) (CPT in

patients history 8924 8924

® examination for 76641: to

breast and

be with

only

physical unilateral,

breast pain.

(clinical 0.5%.

39

pain exam, www.eviCore.com

39 complete breast Page 16of22 and V1.0

or

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______  Breast  Alternative © 2019 While New investigational Positron EmissionMammography here reast oned er mpedance hermography ET uclear

Imaging eviCore healthcare eviCore I T P N    for T C CT transmission, Oth    time  

and/or

BR-8:

alternative

this modality, and this procedure should be considered investigational at this levels. Of these, 3.6% of the women had tumors seen only with PEM. need for MRI hadgreater lesion showed that PEM and MRI hadcomparable breast women underwent both high- breastcancer ant A prospective multi modalities well as in detecting incidental breast cancers not seen on other imaging identified as suspicious onconventional imaging or physical examination, as Early clinical trials have shown high clinical accuracy in characterizing lesions technique is especially adept at detecting ductal carcinoma in situ. and allows visualization of intraductal as well as invasive breast cancers. This The spatial resolution of breast Molecular Scintimammography Th high Systems, also referred to as Naviscan™ or PET mammography, performs High Breast Requesting providers often ask for PEM as CPT mammogram. allowing B

Mammography Breast

e PEM e techniques Guidelines is currently insufficient data available to generate appropriateness criteria

Beam -

-

breast resolution positron- alternative resolution ”.

specific

with

Mammography Alternative acquisition of the emission images immediately after the mastectomy. PEM had greater specificity at the breast and lesion

Imaging detectors are integrated into a conventional mammography system,

breast CT breast nitrous

. All All .

imaging,

respect

Breast to

gamma Rights Reserved. Rights metabolic imaging for breast cancer using anFDG tracer.

breast

detect (PEM)

imaging imaging i oxide cipating breast Approaches - center clinical trial for women with newly

to including:

-

both imaging

imaging level sensitivity and more accurately depicted the oxygen production

this technique is at the individual duct level (1.5 mm) emission mammography (PEM) by Naviscan™ PET

(MBI) Breast techniques screening resolution PEM imaging and breast MRI. Results

consumption, techniques (BSGI) - - conservation surgerywas performed. These Practice

Imaging

may

and

have

8924 8924 diagnosis include: Notes

light FDA ® 78811 or “PET scan of the

Approaches absorption, - level sensitivity, although

approval, of

breast

diagnosed

microwave www.eviCore.com

cancer. they Page 17of22

remain

V1.0

Breast Imaging - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Breast © 2019

Imaging eviCore healthcare eviCore 

mammography. The radiation exposure from a PEM study is 23 times hig Guidelines . All All .

Rights Reserved. Rights 8924 8924 her thanher digital for www.eviCore.com Page 18of22 V1.0

Breast Imaging Breast Imaging Guidelines V1.0

BR-9: Suspected Breast Cancer in Males  Breast cancer in men presents as a mass, skin/nipple change, or pathologic nipple discharge.  For men <25 years of age with an indeterminate palpable mass, ultrasound is recommended as initial imaging followed by mammography if ultrasound is inconclusive or suspicious.  For men ≥25 years of age with an indeterminate palpable mass or with a concerning physical examination, mammography is recommended initially followed by ultrasound if mammography is inconclusive or suspicious.  There is limited evidence on the use of MRI in the evaluation of male breast disease.  Further diagnostic pathway for suspicious clinical or imaging findings usually requires tissue diagnosis. Imaging Breast

______©2019 eviCore healthcare. All Rights Reserved. Page 19 of 22 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com 11. CD, Lehman 10. of College American 14. .Dorrius 9. .Mend 4. 8. 3 Emaus 13. BL, Sprague 3. 7 Mc 17. 12. 16. .National 5. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______15. MB, Mainiero 2. 1. Reference Breast .Moy 7. .Peter 6. © 2019 Guidelines™) Cancer. Testing. NCCN 2013 detection trial systematic review detection ultrasonography P 1134. screening MRI findin rights based Gynecologists. Oncology Thyroid NCCN. the may herein at Saslow complete for Ann https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/bre November Final Sickles - Dense - Publications/Committee by diagnosed ast Breast screening br NCCN.org. Cancer Comprehensive Siu - inel las, east

Carthy - Imaging eviCore healthcare eviCore

any cancer AL.

study

Intern as L, ;

s s gs

Recommendation elson Giroux breast reserved. – 200(6):W683

practice

lesions.

Guidelines of

G, NHG,

system data and reporting imaging

Breasts

Elias

purpose MJ, an ? EA

MD, D, for Screening

Carcinoma.

Referenced National Cancer Comprehensive

s s

surgical Journal American

novice among of

of version . (NCCN

design

CM, for

-

Boetes adjunct

Journal Med. 2016.

review

screening D’Orsi and To EB,

Guidelines not Bakker V

breast

reporting imaging K, FM,

Stout

Blume

Borel

rupture: A, Lourenco mammography an der

for

view

- Pusi

Radiology

to approach Obstet

in be reproduced - Diagnosed Pate Böhm

The

without 2016 screening

.

Breast C Comprehensive El

methods Guidelines™) Radiology

Version - meta and NK, NK, C,

to

of cancer Rinkes

c c

MF,

most the Khoury the JD,

Referenced l W689

NCCN

with Obstetricians

. MC Weide A, mammography Burke

V, the ; - breast

do U.S. . All All .

Vélez Gynecol CJ. - 164(4):279

Schechter

Statement: Kerrigan and NCCN

Peeters the et DeMartini Network, breast experienced and - Opinions/Committee Cancer

American permission ; 2008

. in Rights Reserved. Rights

ACR 2.2017. Mahoney al. IH for

by and spectrum

W, of patient Guidelines™ express MM,

.

analysis

M, cancer: 50 aged women

M, . recent 2015

-

Is

food Roentgenology . Mammography#here Opinion Committee with women

. and Guidelines, et

J, J,

Berg BI Breast 246(1). Zuithoff ; 2015

for PHM,

2.2017 with Trop any

Network

al. Inc.

Ooijen van -

C, ; WB,

296. Gynecologists. and

Invasive

RADS

ca and system data Breast College

ancer Breast 277(2).

complete and

. written

MC,

. Cancer American US from et from permission WA, form

CL.

CA re? Eur

All I, . 125

et

MRI et al. drug

© et NP

Preventive

® National 2014

al. rights

Cancer et and

Plastic

Silicone

of . Network

al.

Radiol. NCCN the

(NCCN) et

Cancer: for al. Benefits Cancer Follow breastsdense go Reston,

https://www.acog.org/Resources A,

permission of Breast al. helpful

findings imaging MR

recommendations administration al.

Accuracy

-

PM . medical Continuing

on- illustrations 75 any

to online Radiology et

; 1 ; 2009

ACR

reserved. .

ACR

& & as Imaging MRI J J al. College American Gynecologic A, years

-

August

purpose breast

up

of version No.

Screening (NCCN)

, Guidelines Cancer: Reconstructive Clin . . Screening

in

VA, et - Meta Services harms, Appropriateness

Clinical

BI

and Outcome readers

evaluationthe

the

al.

93(4) 625

Management

Society and

with

of - NCCN.org ; 2007 of College American Cancer Comprehensive RADS .

implants may herein

Computer . The ; 2011 analysis ; 2013 NCCN NCCN. the Ann

American

without

interpretation

Guidelines Principles : and cost 8924 8924 extremely an

- 986 .

the Practice . Task - and

Radiographics 57( NCCN Practice/Management Version G ® Journal American

U.S.

Intern additional

– 21(8):1600 - 10(1):11 Ultrasound. NCCN uidelines 993 Clinical

2)

education:

.

Diagnosis

magnetic and

of Surgery: the

Force - - :75 of Services Task Preventive Monitoring.

Aided -

of of

.

MR

effectiveness College

Guidelines™

To

Criteria not

Med Guidelines

Radiology of

breasts dense

– – 2.2017 express 2.2017: Version with women mammographic inconclusive

89. Guidelines,

Breast Dedicated view

Practice

imaging 14. time statement. recommendation be modality screening

. for in Detection

; ; 2015

April

1608.

- . ACR In: reproduced 2.2017. breast Radiology ®

And

of

2013

breast the

of reflect

Breast

written

In:

May . Obstetricians

of of Network,

resonance

computer 2008 -

in 2013 most - 162(3):157 in Guidelines .

; ACR illustrations and of

www.eviCore.com

Roentgenology

Oncology breasts dense reconstruction: go 33(2):

the

-

screening : ©

17, BI an of

supplemental cancer The 2017 ; .

of permission

. - to online Page 20of22 Breast - recent

(4 121 Breast

Women RADS di

BI - evidence 2013. in 2017.

agnosis 435- Inc.

- - DENSE

MRI aided RADS

any National imaging

in ): for (

166

and Force and ® All MRI V1.0 453. - 1127 NCCN

with

form -

Atlas, With the . ®

of : A : . -

Breast Imaging 21. 28. 0 T 20. 0 Moy 30. 29. Grau 19. 3 Morris 23. CD, Lehman 27. 26. 25. 22. 24. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______18. Breast © 2019 Clinical (NCCN) NCCN 2012 for andsurveillance workup of Clinical (NCCN) NCCN recently RADS online NCCN Network Institute online of permission illustrations Lim permiss illustrations pathologic Reconstructive Guidelines, written and Gu NCCN Guidelines, written written and and NCCN NCCN Network NCCN National National NCCN the (NCCN) © © © Institute Radiology Holmich 2014 2014 2014 an

the idelines, Imaging eviCore healthcare eviCore

HS illustrations illustrations illustrations H, L, ; AM

81(1) College American

® to to

National National National

Z EA, Guidelines Guidelines Clinical Guidelines Guidelines Clinical Guidelines of permission of permission of permission

Newell

Practice Practice

ion Atlas,

et L

breast diagnosed

for

for Guidelines Guidelines Guidelines S, hang Cancer Comprehensive Cancer Comprehensive (NCCN) (NCCN) , NCCN.org NCCN.org.

. R,

Bapsi

al. correlation. Clinical

Comstock

2013. : of Guidelines Clinical Clinical herein herein go go go e62-

I, Vejborg Gatsonis

P

NCCN. the NCCN. the

Breast

MS,

online online online Practice Practice aget Surgery Comprehensive Comprehensive Comprehensive

herein herein herein

C, Guidelines Guidelines 69..

Liu Guidelines Guidelines

Version Version Version Version Version

may may

Practice

Mahoney h R, h Chug

. Systems Improvement Systems Version Version Version D

H,

the the the Reporting Imaging to to to of isease CE,

. All All .

Radiographics C,

may may may

Conrad :

et not not Guidelines Guidelines

NCCN.org NCCN.org NCCN.org. of July

NCCN.

NCCN. NCCN.

To To

Kuhl

al, Lee CH, cancer.

Rights Reserved. Rights 2.2017: 2.2017: 2.2017: 2.2017: 1.1017:

Radiology

be reproduced be reproduced

Guidelines in in local not not not 2.2017: 2.2017:

2.2017:

Version view Version view Improvement findings Imaging MC, ; 1 ; 2004 et

Oncology Oncology C,

CK,

the

in be reproduced in be reproduced in be reproduced r r Cance Cancer Cancer al.

To To To Network, Network, recurrence

N most the most the et et

. . Invasive Ductal Phyllodes Paget’s Breast et Phyllodes in breast: in et

view view view Breast Breast Breast

al. al Engl 14

2.2017:

2.2017: . . Oncology Oncology al. al.

; 2011 . ; ; 2016 in

(1): ACR Untreated

Network, Network, Network,

and (NCCN (NCCN ACR

MRI J J most the most the most the Oncology

in Carcinoma

Cancer

in in mammographic,

(ICSI) - 204 Diagnosis (ICSI). Inc. Inc.

Disease. recent recent Cancer. Cancer. Cancer. . Med Breast

31(7) 13(11):43 and System. Data

Appropriateness any any Breast Breast Tumor

tumors evaluation

BI in

All All 214 (NCCN (NCCN

- Guidelines™) Guidelines™) phyllodes

;

RADS

distant form form 2007

any any any Inc. Inc. I

; Jan. 2012 Risk

nc. and rights rights and Silicone

t recen recent recent

Cancer . - 1973

(NCCN

Referenced Referenced Breast Cancer. Cancer. National National

of

form form form All All All

- for for complete v complete ; March

Reduction

® 52.

Guidelines™) Guidelines™) breast. the

Situ.

reserved. reserved. metastases of

Magnetic rights rights rights 1987.

complete and complete and complete and any any

Breast tumors for for for

National contralateral the Reston, Cancer. Guidelines™) US, 8924 8924

45 p. of

Referenced Referenced National

Comprehensive Comprehensive

purpose purpose

criteria any any any

- 356(13):1295 for for breast reserved. reserved. reserved.

and of version with with

of ersion

National

Implant Breast Breast

purpose purpose purpose The The of Imaging. Resonance

UpToDate,

VA, Referenced C

MR

in

breast. the permission permission

om sta for disease. for Cancer Comprehensive

without without NCCN NCCN asymptomatic

version version version American

findings imaging

ge

C prehensive

The The The Cancer Cancer Breast Breast with with

for Rupture,

Cancer Comprehensive the the I

without without without breast

1303. breast Breast

NCCN NCCN NCCN

Cancer Cancer

from permission from permission Guidelines™ Guidelines™

6/2017 the the NCCN NCCN (MN): Bloomington

of of of

with Eur Cancer Cancer

from from 2.2017 2.2017

of College

NCCN the NCCN the NCCN the express express

in www.eviCore.com the the the

Plastic

J J cancer:

Cancer

from permission Guidelines™ Guidelines™ Guidelines™

with women

. wo Guidelines, Guidelines, Network Network NCCN the NCCN the ancer Radiol express express express Page 21of22

In: 2.2017 2.2017 men. © ©

with 2014 2014 &

written written

ACR

and and initial 2.2017 Network .

Jan

Journal V1.0 the the

BI

go go -

Breast Imaging 39. 35. 38. 34. 36. 43. 41. 33.

40. 45. 44. 32. 37. - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______42. 31. Breast © 2019

Expert Radiol. ultrasound, - 209(6):1404 the for Morrogh Lee CH, Bahl Roentgenolog Journal pathologic Referenced of College Expert resonance Guidelines™) National NCCN Guidelines, express Centers Women Berger Treatment. Guidelines™ https://www.cdc.gov/genomics/gtesting/file/print/fbr/BCAnaVal.pdf complete for complete for rights rights Discharge. bilateral Monticciolo Golan Koning Lee 3 from Screening. Berg of Cancer Referenced NCCN NCCN Guidelines™) National 8 .201

Radiolo

Imaging eviCore healthcare eviCore evaluation the any any Society SJ,

M, NCCN the WA

reserved. reserved.

O,

Jokich Im, MB, Mainiero Im, Guidelines Guidelines Guidelines

N, purpose purpose © ; 7 ; 2010

Breast

Network

of MA, Gadd

Trikha

at for mastectomy written 8 8 201 Dershaw Cancer Comprehensive Cancer Comprehensive M,

.

Amitai of version of version

gy.

Luparia

Current Nuclear Radiology

nipple Higher

imaging

Journal CollegeAmerican

- 2018;174(2):463 Guidelines other and of Disease go DL, Morris with with

1410.

and

2014(5S). y.

National for for Breast

CT. online - (1):18

S,

permission Newell Clinical The The

without without August Y, (NCCN)

from permission

from permission

discharge: Breast - Breast

of illustrations Moy PM,

- Than

DD, Version status

L, berman Version Version A,

Medicine CD. Lehman E Koning Barnea of

in

the the pathologic Control

A, NCCN NCCN

.

Di

and the and Imaging

to 27

technologies the - 2018;15(3):408 the

. All All .

Bailey

L, Kopans Cancer Comprehensive

Li

MS,

NCCN NCCN G, Practice

; 2017 the the NCCN.org.

Risk: Average . .

Cancer

Cancer Moy

of et Guidelines American reconstruction: management

3.

Rights Reserved. Rights 9, 3.201 Corporation. 3.2018, et

Y, of

dedicated

al express express Guidelines™ Guidelines™ . a Moy (CDC). Prevention and Feb 2016 . 2019

468.

L,

al. . L, herein of NCCN. the Menes - 209(2):465 systematic

ACR Guidelines, Guidelines,

D, nipple

et

3.

et Diagnostic

Radiology Diagnostic 3.2019

Guidelines L,

Network Network

NCCN the NCCN the

- doi:10.1007/s10549

et

al. 2019

al.

Genetic/Familial Genetic/Familial Breast for

Niell

College et

Appropriateness written written al.

may

Version

ACR TS.

ACR

. discharge nuclear ; . . 414 ACR

al. the Recommendations

57(Supplement Breast of http://koninghealth.com/en/kbct/.

© © B, a

magnetic urveillance

National 2019 Nati 2019 To The and and

Y

not review 471. Cancer

. discharge nipple (NCCN) (NCCN) detection

.

Appropriateness u cohort retrospective

go go ield Appropriateness Monsees

permission permission use on the of Performance - 14(11s):s383

in

of

Clinical Clinical view tility

3.201

be reproduced

illustrations illustrations predictive

breast

to online to online Oncology

Radiology cancer

of Network,

and American

of

s the Screening

8: Guidelines Guidelines onal

High - High MRI of

Practice Practice

imaging. B, Breast Criteria - meta

most

screening 018-

clinically

of

of of 1):46S NCCN.org. NCCN.org Sickles Cancer Comprehensive Cancer Comprehensive

value

after (NCCN

. Risk

Inc.

Risk mammography, s390.

may herein may herein NCCN. the NCCN. the ; 2017 From

- 05077

recent analysis

Journal

8924 MRI

Criteria Ann Criteria Cancer. ®

in

and

Guidelines Guidelines All

negative - Assessment: Society Version Version Assessment: of Evaluation

52S.

any

study. EA. occult

14 ACR.the rights Guidelines™) Oncol Surg versus

with ductography Diagnosis

. . . complete and 9.

- (5):138 ®

. form of . . ® Breast

AJR.

Breast

Referenced

Breast imaging: To To

not not

Roentgenology

3.

of Breast breast

3.2019: reserved. or

galactography

imaging resonance : 2019

for in view view in breast

Accessed

be reproduced be reproduced

of mammography inconclusive breast Journal Journal American

153. Oncology Oncology

Cancer .

Breast

any

Breast . Nipple Pain. National Cancer

2007

cancer.

Cancer the the

and

recommendations Breast Breast for

imaging

purpose

Network, Network, version MRI, The

with

most most

College American ; of Breast

magnetic

and and Ovarian. www.eviCore.com Screening 14; March

J J

the

. (NCCN (NCCN

Comprehensive NCCN

and Research

Cancer. Cancer permission breast

; 2017

in Page Am recent recent 3369 . Ovarian

of white

American in in

without women

Cancer Inc. Inc.

18,

the any any Coll

after . .

of 22 .

in and and All All r. r. pape 2019.

V1.0 NCCN

form form

of

the

with from 22

Breast Imaging