BlueCross BlueShield of Tennessee Medical Policy Manual

General Policy for Breast Diseases or Conditions

PURPOSE

To establish a basis for determining medical necessity related to diseases or conditions of the breast.

DESCRIPTION

Conditions or diseases of the breast, such as breast lesions, cysts, lumps, fibromas, cancer, deformities resulting from a mastectomy, unilateral agenesis or marked hypoplasia (absence or defective development), fibrocystic disease, hyperplasia or hypertrophy, gynecomastia, mastitis, or mastodynia.

POLICY

• BlueCross BlueShield of Tennessee recognizes the need for consistency in the determination of medical appropriateness for services provided in relation to diseases of the breast.

• Services will be considered medically appropriate only if they have met BlueCross BlueShield of Tennessee's technology evaluation criteria.

DIAGNOSTICS:

• Breast Duct Endoscopy

• Breast Ductal Lavage for Cancer Risk Assessment

• Computer-Aided Detection of Malignancy with Magnetic Resonance Imaging of the Breast

• Cytologic Evaluation in Breast Cancer Risk Assessment

• Digital Breast Tomosynthesis

• Electrical Impedance Scanning of the Breast

• Gene Expression Profiling Assays as a Technique to Determine Prognosis for Managing Breast Cancer Treatment

• Genetic Testing for BRCA1, BRCA2 or CHEK2 for Breast or Ovarian Cancer

• Genetic Testing for HER-2

• Magnetic Resonance Imaging (MRI) of the Breast

• Mammography Screening

• Non-BRCA Breast Cancer Risk Assessment

• Positron Emission Tomography (PET) for Oncologic Applications

• Serum Tumor Markers for Breast Malignancies

THERAPEUTICS:

• Abdominoplasty / Panniculectomy / Lipectomy

• Brachytherapy for Breast Cancer

• Breast Augmentation / Mammaplasty (Non-Cancerous)

• Breast Implant Removal

• Breast Reconstructive and Symmetry Surgery following Mastectomy

• Cryosurgical Ablation of Miscellaneous Solid Tumors

• Hematopoietic Stem Cell Transplant for Breast Cancer

• High Dose (Myeloablative) Chemotherapy with Bone Marrow, Peripheral Stem Cell, or Cord Blood Transplant for Hematopoietic Stem Cell Support

• Liposuction

• Lymphedema Devices

• Manual Lymphedema Drainage (MLD)

• Mastectomy for Gynecomastia

• Prophylactic Mastectomy

• Reduction Mammaplasty (Non-Cancerous)

ORIGINAL EFFECTIVE DATE:  11/10/1997

MOST RECENT REVIEW DATE:  6/22/2011

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.