Breast Imaging Guidelines

This policy covers breast imaging services—including screening and diagnostic mammography, breast ultrasound, breast MRI, and imaging related to nipple discharge, breast pain, reconstruction, and suspected male breast cancer—organized by BI-RADS categories and specific imaging indications. It applies primarily to patients with common breast symptoms and symptom complexes; imaging for atypical or unaddressed presentations requires physician review/consultation. Major limitations/requirements: routine ultrasound is not appropriate as a stand‑alone screening test (including for density alone), BI-RADS Category 3 requires short‑interval follow‑up (6, 12, 18, 24 months then reclassify if stable), Category 4 generally prompts biopsy consideration, and the document is a clinical decision support tool (not a fee schedule) so atypical requests may need additional clinical review.

"These lesions have been biopsied and are known to be malignant."