Breast Imaging Guidelines

This policy covers breast imaging services including diagnostic and screening mammography, breast ultrasound, breast MRI, and related evaluations (e.g., nipple discharge, breast pain, reconstruction assessment, male breast cancer, and imaging in pregnant or lactating patients). Major limitations: advanced imaging generally requires a current clinical evaluation within 60 days (except screening studies), atypical presentations require physician review, routine standalone or adjunctive ultrasound screening (including for dense breasts) is not indicated, and Category 0 (incomplete) findings must specify the additional imaging needed.

"MRI Breast carries a significant false positive risk when compared to mammogram and ultrasound."

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