BlueCross BlueShield of Tennessee Medical Policy Manual

Positron Emission Mammography

DESCRIPTION

Positron emission mammography (PEM) is a form of positron emission tomography (PET) that uses a high-resolution, mini-camera detection technology for imaging the breast. As with PET, a radiotracer, usually 18F-fluorodeoxyglucose (FDG) is administered and PEM provides functional rather than anatomic information about the breast. PEM has been studied primarily for use in presurgical planning and staging; it also has been used to monitor therapy response and breast cancer recurrence.

POLICY

See also: Magnetic Resonance Imaging (MRI) of the Breast

IMPORTANT REMINDERS

ADDITIONAL INFORMATION  

Published clinical studies comparing PEM to existing modalities are limited, and impacts on net health outcome are uncertain. Therefore this procedure remains investigational.

SOURCES 

American College of Radiology. ACR Appropriateness Criteria┬« (2012, reviewed last in 2016) Breast cancer screening. Retrieved April 6, 2017 from  https://acsearch.acr.org.

American College of Radiology. ACR Appropriateness Criteria┬« (2012, reviewed last in 2016) Palpable breast masses. Retrieved April 22, 2014 from  https://acsearch.acr.org.

Berg, W., Madsen, K., Schilling, K., Tarter. M., Pisano, E., Larson, L., et al. (2011). Breast cancer: Comparative effectiveness of positron emission mammography and MRI in presurgical planning of the ipsilateral breast. RSNA Radiology, 256 (1), 1-19. (Level 3 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2016). Positron Emission Mammography (6.01.52). Retrieved April 6, 2017 from BlueWeb. (30 articles and/or guidelines reviewed)

ECRI Institute. Health Technology Information Services. (January, 2013) AHRQ Comparative Effectiveness Review Surveillance Program. Retrieved June 11, 2015 from ECRI Institute. (5 articles and/or guidelines reviewed)

Heusner, T., Hahn, S., Jonkmanns, C., Kuemmel, S., Otterback, F. et.al. (2011) Diagnostic accuracy of fused positron emission tomography/magnetic resonance mammography: initial results. The British Institute of Radiology. 10.1259/bjr/93330765. (Level 3 evidence)

National Comprehensive Cancer Network (2016, July) NCCN Guidelines ® Breast cancer screening and diagnosis. Retrieved April 6, 2017 from www.nccn.org.

Schilling, K., Narayanan, D., Kalinyak, J., The, J., Velasquez. M., Kahn, S., et al. (2010) Positron emission mammography in breast cancer pre-surgical planning: comparisons with magnetic resonance imaging. European Journal of Nuclear Medicine and Molecular Imaging, 38 (1), 23-36. (Level 3 evidence - Industry sponsored)

U. S. Food and Drug Administration. (2003. August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K032063. Retrieved March 22, 2011 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2008. November). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K082354. Retrieved March 22, 2011 from http://www.accessdata.fda.gov.

U. S. Preventive Services Task Force (2016, February) Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Retrieved April 6, 2017 from: www.USPreventativeServiceTaskForce.org.

Yoon, J. H., Kim, M. J., Kim, E. K., & Moon, H. J. (2015). Imaging surveillance of patients with breast cancer after primary treatment: current recommendations. Korean Journal of Radiology,16 (2), 219-228. (Level 2 evidence)

ORIGINAL EFFECTIVE DATE:  7/9/2011

MOST RECENT REVIEW DATE:  6/8/2017

ID_EC

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.

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