Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27502

Magnetic Resonance Imaging (MRI) of the Breast

L27502

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare 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 1862(a)(7).  This section excludes routine physical examinations.

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, Chapter 1, Section 220.2

CMS Online Manual Pub. 100-4, Chapter 13, Section 40

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Magnetic resonance imaging (MRI) of the breast is a radiological tool for the detection and characterization of breast disease, assessment of the local extent of disease, evaluation of treatment response, and guidance for biopsy and localization.

MRI findings should be correlated with clinical history, physical examination, and the results of other imaging examinations to enhance the probability of accurate results. Caution should be exercised in changing management based on MRI findings alone in patients with breast malignancy, as most mammographically occult lesions are successfully treated with irradiation and/or chemotherapy following surgical removal of the known lesion.

Covered Indications

Breast MRI may be indicated for any of the following:

1. Lesion characterization - Physical examination, ultrasound and mammography are inconclusive for the presence of breast cancer. This is expected to be relatively uncommon, because breast MRI is not indicated in lieu of biopsy (e.g., mammogram is a BI-RADS^® 4 or 5), if biopsy is feasible.
   
   
2. Neoadjuvant chemotherapy - Before, during, and/or after a course of chemotherapy to evaluate chemotherapeutic response and residual disease prior to surgical treatment.
   
   
3. Determination of the extent of disease for all newly diagnosed breast cancer patients, where the type of cancer is defined as infiltrating ductal and/or lobular carcinoma, and/or ductal carcinoma in situ (DCIS).
   
   
4. Axillary adenopathy, primary unknown - Patients who present with axillary adenopathy and no mammographic or physical findings of primary breast cancer.
   
   
5. Postoperative tissue reconstruction - Evaluation of suspected cancer recurrence in patients with tissue transfer flaps or implants.
   
   
6. Silicone and non-silicone breast augmentation – Evaluation of patients with silicone implants and/or injections, and patients with non-silicone implants.
   
   
7. Carcinoma invasion deep to fascia - Prior to surgery to determine the extent of disease.
   
   
8. Contralateral breast examination in patients with breast malignancy.
   
   
9. Postlumpectomy for residual disease - Evaluation of residual disease in patients who have not had preoperative MRI and whose pathology specimens demonstrate close or positive margins for residual disease.
   
   
10. Recurrence of breast cancer - Patients with a prior history of breast cancer and suspicion of recurrence when clinical or mammographic findings are inconclusive, or when post op scar tissue cannot be differentiated from tumor.

Coverage Limitations

1. Screening breast MRI is a non-covered service, that is statutorily excluded at this time. There is no benefit category for MRI of the breast in the fee-for-service Medicare Program, without signs or symptoms of breast disease.
   
   
2. A breast MRI for diagnosis of neoplasm of unspecified nature of bone, soft tissue and skin is acceptable only when related to the breast (i.e., metastasis).
   
   
3. Breast MRI should be performed under the general supervision of a physician qualified in magnetic resonance imaging.
   
   
4. A treating provider's (physician or qualified non-physician practitioner) order is required for breast MRI.
   
   
5. MRI of the breast is not covered, as per the CMS National Coverage Determination (NCD) 220.2 C., when any of the following contraindications are present:
   

   ·	Cardiac pacemaker
   ·	Metallic clips on vascular aneurysms (e.g., ferromagnetic intracranial aneurysm clips)
   ·	Pregnancy
   ·	Certain other ferromagnetic implants, devices, foreign bodies, or electronic devices (e.g., certain neurostimulators, certain cochlear implants)

6. An additional possible contraindication to breast MRI is lactation.

Diagnostic Tests and X-Rays

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
   
   
4. Documentation in the patient's medical record should include all of the following: a current, pertinent history and physical examination, and progress notes describing and supporting the covered indication; pertinent prior diagnostic testing and completed report(s); a written request for the breast MRI containing appropriate clinical history and reason for the examination completed by, or under the supervision of, the referring physician.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Berg, W. A., Gutierrez, L., et al.  Diagnostic Accuracy of Mammography, Clinical Examination, US, and MR Imaging in Preoperative Assessment of Breast Cancer.  Radiology.  Available at http://radiology.rsnajnls.org/cgi/content/full/233/3/830.  Accessed on May 19,2008.

Bevers, T. B., Anderson, B. O., et al.  National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology, Breast Cancer Screening and Diagnosis Guidelines.  Available at http://www.nccn.org.  Accessed on May 19, 2008.

Esserman, L. J., Joe, B. N.  Diagnostic Evaluation and Initial Staging Work-Up of Women with Suspected Breast Cancer.  UpToDate.  Available at http://www.utdol.com/online/content/topic.do?topicKey=breastcn/13029&view=print.  Accessed on May 17, 2008.

Food and Drug Administration.  Making an Informed Decision about Breast Implants.  Available at http://www.fda.gov/fdac/features/2004/504_implants.html.  Accessed on May 17, 2008.

Lehman, C.D., Gatsonis, C., et al.  MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer.  NEJM.  Available at http://content.nejm.org/cgi/content/full/356/13/1295.  Accessed on May 19, 2008.

Liberman, L., Morris, E. A., et al.  MR Imaging of the Ipsilateral Breast in Women with Percutaneously Proven Breast Cancer.  Am J Roentgenology.  Available at http://www.ajronline.org/cgi/content/full/180/4/901?maxtoshow=&HITS=10&hits=10&...  Accessed on May 19, 2008.

Stuebe, A., et al.  Principles of Medication Use During Lactation.  Up To Date.  Available at http://www.utdol.com/online/content/topic.do?topicKey=postpart/2447&view=print.  Accessed on May 17, 2008.

Warner, E., Messersmith, H., et al.  Systematic Review:  Using Magnetic Resonance Imaging to Screen Women at high Risk for Breast Cancer.  Ann Intern Med. 2008;148:671-9.

Wilkins, E., Atisha, D.M.  Breast Reconstruction in Women with Breast Cancer.  UpToDate.  Available at http://www.utdol.com/online/content/topic.do?topicKey=breastcn/13517&view=print. Accessed on May 17, 2008.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27502

07/31/2008

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