LCD L33585: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography

Abstract:

This LCD describes magnetic resonance imaging of the breast, ultrasonic evaluation of the breast, and ductography.

Breast sonography is the ultrasonic evaluation of an abnormal breast lesion.

Breast MRI is the application of magnetic resonance principles to breast imaging.

Ductography (galactography) is a contrast-enhanced visualization of the breast ducts.

Indications:

Breast Sonography

Breast sonography may be indicated for conditions such as:

• Guidance for breast interventional procedures

• Assessment of implant related problems

• Radiation treatment planning

• Initial evaluation of palpable masses in women under 30

• In lactating and pregnant women

• Assessment of palpable abnormalities on physical exam

• Assessment to distinguish simple mastitis from abscess formation

• Assessment of any mass to determine whether it is suitable for percutaneous intervention (core biopsy, for instance)

• Assess stability of a sonographically visible mass that is mammographically invisible

• Non-palpable masses, detected by mammography, to differentiate cysts from solid lesions

• Palpable masses, if needle aspiration is not performed

• Symptomatic, possible ruptured silicone breast prosthesis when an MRI is not possible

• Calcifications to determine if an invasive component exists that would be amenable to core biopsy when supported by additional clinical indications.

Breast ultrasonography should not be routinely used along with diagnostic mammography. Ultrasonography may be indicated in addition to diagnostic mammography for the evaluation of some ambiguous mammographic or palpable masses or focal asymmetric densities that may represent or mask a mass.

Breast ultrasonography may be performed, in some cases, without having a diagnostic mammography first. However, an order from the treating physician for the ultrasonography is required. For example: a 22-year-old female presents with a painful breast lump. An ultrasound is performed and documents a large simple cyst, which subsequently is aspirated and resolved without the need for a prior diagnostic mammography.

A treating provider's (physician or qualified non-physician practitioner) order is required for breast ultrasound. This requirement is not applicable to hospital based radiologists for inpatient or outpatient breast ultrasound.

Breast sonography should be performed under the general supervision of a physician qualified in breast ultrasonography.

Breast MRI

Breast MRI studies are to be used very selectively. The modality should be restricted to:

• cases where diagnosis is inconclusive, even after standard work-up;

• evaluation of the post-operative patient when scar tissue cannot be differentiated from tumors;

• patients with positive axillary nodes but no known primary;

• patients with rupture of a breast implant; or

• determination of the extent of disease in patients with known malignancy, prior to treatment (to assure confinement to one segment of the breast).

Breast MRI should be performed under the general supervision of a physician qualified in magnetic resonance imaging.

A treating provider's (physician or qualified non-physician practitioner) order is required for breast MRI. This requirement is not applicable to hospital based radiologists for inpatient or outpatient breast MRI.

Ductogram (Galactogram)

Ductography is useful as an aid in diagnosing the cause of an abnormal nipple discharge and is valuable in diagnosing intraductal papillomas.

Ductography should be performed under the personal supervision of a physician qualified in ductography.

A treating provider's (physician or qualified non-physician practitioner) referral is required for ductography. This requirement is not applicable to hospital based radiologists for an inpatient or outpatient ductogram (galactogram).

Limitations:

• There is no separate transportation cost allowed for other breast imaging procedures. To receive transportation payments, the approved portable x-ray supplier must also meet the certification requirements of Section 354 of the Public Health Service Act.

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