Breast Imaging Guidelines

This policy covers breast imaging services—including diagnostic and screening mammography, breast ultrasound, breast MRI (gadolinium required for parenchymal evaluation), implant assessment, and reconstruction-related imaging—using BI-RADS categories for indications such as nipple discharge, breast pain, suspected or known malignancy, and male breast cancer. Key limitations/requirements: ultrasound is not appropriate as stand-alone screening or solely for dense breasts; BI-RADS 3 lesions use short-interval follow-up while BI-RADS 4–6 generally prompt biopsy or treatment; atypical presentations require physician review/consultation; and imaging-specific contrast, coding, and state density-reporting mandates must be followed.

"BR-1: Breast Ultrasound"

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