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Coverage criteria policies

Breast Specific Gamma Imaging (BSGI)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not applicable for Breast Specific Gamma Imaging (BSGI) because it is considered experimental / investigational. The provider and facility will be liable for payment unless:

  • The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and
  • The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and
  • The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Coverage

Breast Specific Gamma Imaging is considered experimental/investigational and is therefore not covered.

Definitions

Breast Specific Gamma Imaging (BSGI) - a breast imaging procedure that captures the metabolic activity of breast lesions through a radiotracer uptake. A small amount of tracing agent is delivered to a patient, and is absorbed by all cells in the body. The tracing agent emits invisible gamma rays, which are detected by a gamma camera and translated into a digital image of the breast. The cancerous cells absorb a greater amount of the tracing agent and are revealed as “hot spots” per the breast gamma camera.

Also called Scintimammography, Technetium-99m-Sestamibi Scintigraphy, Miraluma test, and Molecular Breast Imaging.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

78800

Radiopharmaceutical Localization of Tumor, Limited Area

78801

Radiopharmaceutical Localization of Tumor, Multiple Areas (Both breasts imaged)

A9500

Supply of Radiopharmaceutical Imaging Agent - Technetium TC-99 M Sestamibi, per Dose

S8080

Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical.

ICD-10-CM Codes

Codes

Description

C50.011-C50.929

C50.929 - Malignant neoplasm of breast

C79.81

Secondary malignant neoplasm of breast

D05.00-D05.92

Carcinoma in situ of breast

Z80.3

Family history of malignant neoplasm of breast

Z85.3

Personal history of malignant neoplasm of breast

Z12.31

Encounter for screening mammogram for malignant neoplasm of breast

Z12.39

Encounter for other screening for malignant neoplasm of breast

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Brem, R. F., Floerke, A. C., Rapelyea, J. A., Teal, C., Kelly, T., & Mathur, V. (2008). Breast-specific gamma imaging as an adjunct imaging modality for the diagnosis of breast cancer. Radiology247(3), 651-657.
  2. Brem, R. F., Ioffe, M., Rapelyea, J. A., Yost, K. G., Weigert, J. M., Bertrand, M. L., & Stern, L. H. (2009). Invasive lobular carcinoma: detection with mammography, sonography, MRI, and breast-specific gamma imaging. American Journal of Roentgenology192(2), 379-383.
  3. Brem, R. F., Petrovitch, I., Rapelyea, J. A., Young, H., Teal, C., & Kelly, T. (2007). Breast‐specific gamma imaging with 99mTc‐Sestamibi and magnetic resonance imaging in the diagnosis of breast cancer—a comparative study. The breast journal13(5), 465-469.
  4. Brem, R. F., Rapelyea, J. A., Zisman, G., Mohtashemi, K., Raub, J., Teal, C. B., ... & Welch, B. L. (2005). Occult breast cancer: scintimammography with high-resolution breast-specific gamma camera in women at high risk for breast cancer. Radiology237(1), 274-280.
  5. ECRI Institute. (2011). Breast-Specific Gamma Imaging for Diagnosis and Screening of Breast Cancer. Plymouth Meeting, PA: ECRI Institute.
  6. ECRI Institute. (2013). Breast-specific Gamma Imaging for Breast Cancer. Plymouth Meeting, PA: ECRI Institute.
  7. Hayes, Inc. Hayes Health Technology Brief. Breast-Specific Gamma Imaging (BSGI) Using the Dilon 6800® Gamma Camera (Dilon Technologies Inc.). Lansdale, PA: Hayes, Inc.; November, 2010. Reviewed July, 2014. Archived December, 2015.
  8. Liberman, M., Sampalis, F., Mulder, D. S., & Sampalis, J. S. (2003). Breast cancer diagnosis by scintimammography: a meta-analysis and review of the literature. Breast cancer research and treatment80(1), 115-126.
  9. Mainiero, M. B., Lourenco, A., Mahoney, M. C., Newell, M. S., Bailey, L., Barke, L. D., ... & Jokich, P. M. (2016). ACR appropriateness criteria breast cancer screening. Journal of the American College of Radiology13(11), R45-R49.
  10. Slanetz, PJ. MRI of the breast and emerging technologies. In: UpToDate, Chagpar, AB; Elmore, JG (Ed), UpToDate, Waltham, MA. (Accessed on July 25, 2017.)

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Policy activity

  • 10/29/2009 - Date of origin
  • 11/01/2015 - Effective date
Review date
  • 07/2017

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