Digital Breast Tomosynthesis

POLICY NUMBER

L.6.01.418

DESCRIPTION

Digital breast tomosynthesis(DBT)uses modified digital mammography equipment to obtain additional radiographic data that are used to reconstruct cross-sectional “slices” of breast tissue. Tomosynthesis may improve the accuracy of digital mammography by reducing problems caused by overlapping tissue. Tomosynthesis typically involves additional imaging time and radiation exposure, although recent improvements may change this.

Conventional Mammography

Conventional mammography produces two-dimensional (2D) images of the breast. Overlapping tissue on a 2D image can mask suspicious lesions or make benign tissue appear suspicious, particularly in women with dense breast tissue. As a result, women may be recalled for additional mammographic spot views. Inaccurate results may lead to unnecessary biopsies and emotional stress, or to a potential delay in diagnosis. Spot views often are used to evaluate microcalcifications, opacities, or architectural distortions; to distinguish masses from overlapping tissue; and to view possible findings close to the chest wall or in the retro-areolar area behind the nipple. The National Cancer Institute reports that approximately 20% of cancers are missed at mammography screening. Average recall rates are approximately 10%, with an average cancer detection rate of 4.7 per 1000 screening mammography examinations. The U.S. Mammography Quality Standards Act (MQSA) audit guidelines anticipate 2 to 10 cancers detected per 1000 screening mammograms. Interval cancers, which are detected between screenings, tend to have poorer prognoses.

Digital breast tomosynthesis (DBT) was developed to improve the accuracy of mammography by capturing a group of tomograms of the breast, further clarifying areas of overlapping tissue. Developers proposed that its use would result in increased sensitivity and specificity, as well as fewer recalls due to inconclusive results. Digital breast tomosynthesis produces multiple low-dose images per view along an arc over the breast. During breast tomosynthesis, the compressed breast remains stationary while the x-ray tube moves approximately 1° for each image in a 15° to 50° arc, acquiring 11 to 49 images. These images are projected as cross-sectional “slices” of the breast, with each slice typically 1-mm thick. Adding breast tomosynthesis takes about 10 seconds per view. In one study in a research setting, mean time (standard deviation) for interpretation of results was 1.22 (1.15) minutes for digital mammography and 2.39 (1.65) minutes for combined digital mammography and breast tomosynthesis.

With conventional 2D mammography, breast compression helps decrease tissue overlap and improve visibility. By reducing problems with overlapping tissue, compression with breast tomosynthesis may be reduced by up to 50%. This change could result in improved patient satisfaction.

A machine equipped with breast tomosynthesis can perform 2D digital mammography, DBT, or a combination of both 2D mammography and DBT during a single compression. Radiation exposure from tomosynthesis is roughly equivalent to mammography. Therefore, adding tomosynthesis to mammography doubles the radiation dose, although it still is below the maximum allowable dose established in the Mammography Quality Standards Act.

Studies typically compare 1-view (ie, mediolateral oblique view), or more commonly, 2-view (mediolateral oblique plus craniocaudal view) breast tomosynthesis either alone or combined with standard 2D mammography, against standard 2D mammography alone. A 2014 TEC Assessment focused on 2-view tomosynthesis. The U.S. Food and Drug Administration (FDA), which reviewed this new modality in 2011, recommended that 2- view breast tomosynthesis is preferable to 1-view tomosynthesis (both used in combination with full-field digital mammography).

In 2013, the U.S. Food and Drug Administration (FDA) approved new tomosynthesis software that permits creation of 2D images (called C-View) from images obtained during tomosynthesis. As a result, 2D mammography may become unnecessary, thereby lowering radiation dose. In other words, it is possible that only the tomosynthesis procedure will be needed, with the ability to create both conventional 2D and DBT images.It is too early to gauge how traditional mammography plus tomosynthesis compares with C-view plus tomosynthesis.

The table below provides a summary of digital breast tomosynthesis (DBT) systems approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process. FDA product code: OTE. The tomosynthesis portion of the mammography unit is considered a separate mammographic module, and for a facility to use this module, the facility must apply to FDA for certification that extends to the tomosynthesis module. The Mammography Quality Standards Act requires interpreting physicians, radiologic technologists, and medical physicists to complete 8 hours of digital breast tomosynthesis training, and mandates a detailed mammography equipment evaluation before use.

FDA Approved DBT Systems

DBT: digital breast tomosynthesis; FDA: Food and Drug Administration; FFDM: full-field digital mammography.

POLICY

Effective 01/01/2018, screening digital breast tomosynthesis (CPT 77063), is covered once per calendar year as an alternative to standard (2D) mammography for women beginning at age 35 as part of the Healthy You! Wellness benefit. Refer to the  Healthy You! Wellness Procedures medical policy.

Digital breast tomosynthesis may be considered medically necessary as an alternative to standard (2D) mammography for further imaging when used for breast cancer diagnostic purposes.

POLICY EXCEPTIONS

Federal Employee Program (FEP) Members: Benefits are available once per calendar year for screening mammograms, including mammography using digital technology. Refer to the Preventive Care, Adult section of the current Blue Cross and Blue Shield Service Benefit Plan .

POLICY GUIDELINES

Screening mammography is a radiological examination to detect unsuspected breast cancer in asymptomatic women.

Diagnostic mammography is a radiologic examination performed to evaluate patients who have signs and/or symptoms of breast disease, imaging findings of concern, or prior imaging findings requiring specific follow-up.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

1. Consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

2. Appropriate with regard to standards of good medical practice; and

3. Not solely for the convenience of the Member, his or her Provider; and

4. The most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

07/21/2011: Approved by Medical Policy Advisory Committee. 

09/25/2012: Policy reviewed; no changes.

11/06/2013: Policy reviewed; no changes.

09/23/2014: Policy reviewed; description revised. Policy statement unchanged.

02/23/2015: Added HCPCS code G0279 to the Code Reference section.

04/27/2015: Added CPT codes 77061, 77062, and 77063 to the Code Reference section.

07/13/2015: Code Reference section updated for ICD-10.

10/22/2015: Policy description updated regarding tomosynthesis systems. Policy statement unchanged. Investigative definition updated in policy guidelines section.

01/20/2016: Policy description updated. Policy statement unchanged.

05/31/2016: Policy number A.6.01.53 added.

11/09/2016: Policy description updated regarding digital breast tomosynthesis systems. Policy statement unchanged.

10/18/2017: Policy description updated regarding devices. Policy statement unchanged.

12/22/2017: Policy revised to state that effective 01/01/2018, digital breast tomosynthesis is covered once per calendar year as an alternative to standard (2D) mammography for women beginning at age 35 as part of the Healthy You! Wellness benefit. Also, digital breast tomosynthesis may be considered medically necessary as an alternative to standard (2D) mammography for further imaging when used for breast cancer diagnostic purposes. Policy Guidelines, Sources and Code Reference sections updated. Policy number updated to L.6.01.418.

01/25/2018: Code Reference section updated to revise description for HCPCS code G0279.

03/27/2018: State Health Plan removed from Policy Exceptions.

12/21/2018: Code Reference section updated to revise code descriptions for CPT codes 77061 and 77062, effective 01/01/2019.

09/24/2019: Code Reference section updated to add new ICD-10 diagnosis codes N63.15 and N63.25, effective 10/01/2019. Updated link in Policy Exceptions.

10/07/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

10/18/2023: Policy reviewed. Policy statements unchanged. Sources updated.

12/04/2024: Policy reviewed; no changes.

10/01/2025: Code Reference section updated to add new ICD-10 diagnosis codes C50.A0, C50.A1, and C50.A2.

SOURCE(S)

1. ACR Practice Parameter for the Performance of Screening and Diagnostic Mammography, The American College of Radiology, Revised 2013.

2. ACR Statement on Breast Tomosynthesis, The American College of Radiology, November 24, 2014.

3. Breast Tomosynthesis. Cleveland Clinic. https://my.clevelandclinic.org/health/diagnostics/15939-digital-breast-tomosynthesis-and-breast-cancer-screening . Accessed October 2023.

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Medically Necessary Codes

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