Clinical Policy Bulletin: Breast Biopsy Procedures
Aetna considers any of the following minimally invasive image-guided breast biopsy procedures medically necessary as alternatives to needle localization core surgical biopsy (NLBx) in members with abnormalities identified by mammography that are non-palpable or difficult to palpate (i.e., because they are deep, mobile, small (less than 2 cm), or are composed of clustered microcalcifications):
Aetna considers other minimally invasive image-guided breast biopsy procedures (i.e., those not mentioned above) experimental and investigational (e.g., PET-guided breast biopsy [Naviscan]) because their effectiveness has not been established.
Aetna considers radioactive seed localization for breast lesion/cancer experimental and investigational because its effectiveness has not been established.
Recent comparative studies have demonstrated several advantages of minimally invasive breast biopsy procedures over needle localization core surgical biopsy (NLBx). Minimally invasive breast biopsy procedures take less time to perform than NLBx, cause less patient discomfort and cosmetic deformity, result in less artifact on subsequent mammography, and are more cost effective. If a benign lesion is found, the patient can be followed with clinical examinations and mammography and an open surgical procedure is avoided.
Biopsies can be obtained either with a fine-needle (20-gauge) or large bore (11- and 14-gauge) needle. However, the large-core biopsy is favored over fine-needle biopsy for several reasons: (i) large core biopsy samples can be interpreted by pathologists who do not have special training in cytopathology; (ii) specimens obtained by large core biopsy are more likely to be sufficient than those obtained by fine-needle biopsy; (iii) large core biopsy samples allow the pathologist to differentiate in-situ from invasive carcinoma; and (iv) pathologists can characterize lesions more completely with large-core biopsy samples.
For larger, fixed, palpable lesions, image guidance is considered not medically necessary for performing an adequate biopsy. In these cases, palpation-guided biopsy is sufficient for locating the lesion and obtaining an adequate tissue sample. However, image-guidance has been shown to be useful for directing the biopsy of non-palpable or vaguely palpable lesions. The Center for Medicare and Medicaid Services (CMS, 2002) concluded that imagine-guided biopsy may be indicated for lesions that are non-palpable or vaguely palpable, and that “clinical studies suggest that such lesions may include those that are vaguely palpable, mobile, deep, or small, particularly less than 2 cm. Palpable lesions that demonstrate a small area of clustered microcalcifications on a mammogram may be difficult to biopsy using palpation alone and thus may warrant image-guided biopsy. Lesions that are difficult to biopsy using palpation are generally those that border on being non-palpable; non-palpable lesions are not amenable to palpation-guided biopsy.”
Hanna et al (2005) stated that stereotactic breast biopsy techniques minimize the surgical trauma associated with conventional wire-guided open breast biopsy for non-palpable breast lesions (NPBLs). Advanced breast biopsy instrumentation (ABBI) allows for a 2-cm core of breast tissue to be excised under stereotactic guidance in an outpatient setting. These investigators reported their initial experience with ABBI. Hospital charts from 89 ABBI procedures between October 1996 and July 2002 were retrospectively reviewed for patient characteristics, ABBI parameters, radiographic appearance, pathology, complications, and clinical follow-up. Data were presented as percentage/median (range). Median age was 59 years (range of 39 to 80 years), mammographic lesions were classified as calcifications 49 % (44/89), soft tissue 39 % (35/89), or mixed 11 % (10/89). Median radiographic size was 7 mm (1 to 60 mm). Final pathology revealed ductal carcinoma in situ (DCIS) in 7 % (6/89) and invasive cancer in 22 % (20/89). Microscopically clear margins were obtained in 55 % (11/20) of patients with invasive cancer. Of these, 82 % (9/11) chose not to undergo further local surgical therapy. Eight patients remain disease free at 56 months (range of 41 to 95 months) follow-up. The 9th patient was deceased at 6 months from an unrelated cause. The overall complication rate was 3 % (3/89). A definitive diagnosis was obtained in 100 % of malignant and 87 % of benign cases. Median waiting time was 19 days (range of 0 to 90 days). The authors' experience demonstrated that ABBI is an effective diagnostic tool for NPBLs. It is associated with minimal complications, and provides negative margins in over 50 % of malignant cases. In selected patients with invasive cancer and negative margins, ABBI may obviate the need for further local surgical treatment. Furthermore, ABBI merits additional investigation as a therapeutic modality for early breast cancer.
Szynglarewicz et al (2011) compared the procedure duration time for different methods of minimally invasive image-guided vacuum-assisted breast biopsy (VABB). A total of 691 women with non-palpable breast masses classified as BI-RADS IV or V were studied. All of them underwent minimally invasive percutaneous VABB with an 11-gauge needle. In 402 patients an ultrasound-guided procedure with a hand-held device was performed while in 289 women stereotactic biopsy was carried out using a dedicated prone table unit with digital imaging. In each case the duration of biopsy was measured in terms of the total procedure time, room time and physician time. There were no significant differences between the stereotactic and ultrasound-guided groups with regard to patient age, body mass index, menopausal status, history of parity, hormone replacement therapy, breast parenchymal pattern (according to Wolfe's classification), family history of breast cancer, mass size and number of samples. Ultrasound-guided biopsy was found to take significantly less time than prone stereotactic biopsy in every aspect of procedure duration. Mean total procedure time, room time, and physician time in minutes were 26.7 ± 8.2 versus 47.5 ± 9.4 (p < 0.01), 23.1 ± 8.5 versus 36.5 ± 9.2 (p < 0.05), and 12.3 ± 5.6 versus 18.6 ± 5.9 (p < 0.05), respectively. The authors concluded that ultrasound-guided breast biopsy is less time-consuming than the stereotactic procedure for both the patient and the physician. Because of the shorter procedure time (as well as other well-known advantages: real-time imaging, lower cost), ultrasound-guided biopsy should be considered the method of choice for sampling suspicious nonpalpable breast masses.
Radioactive seed localization (RSL) has also been advocated as a means to facilitate the operative excision of non-palpable breast lesions, and appears to be a new option for women undergoing lumpectomies. With this procedure, a radiologist places a very low-energy radioactive seed into the abnormal tissue or tumor, guided by mammography. During the surgery, the surgeon uses a hand-held Geiger counter to more precisely identify the location of the tumor. The Geiger counter also allows the surgeon to obtain a 3-D view of the tumor’s location. On the day of the lumpectomy, the patient arrives about 2 hours before the surgery to receive light sedation and a local anesthetic to numb the surgical area. After the surgeon removes the abnormal tissue or tumor along with the radioactive seed, the incision is closed and bandaged. Once the seed is removed with the breast tissue, the radioactivity is gone. The patient is able to leave the hospital later that same day.
Rao et al (2010) stated that seed localization uses a radioactive source to identify non-palpable breast lesions for excision; it is an emerging alternative to wire-localized breast biopsy (WLBB). Previous single health system studies reported decreased rates of re-excision and improved patient convenience with this technique. This study was the first to implement this procedure in a public health care delivery system composed of a primarily minority and low-income population. A multi-disciplinary team was formed to create a protocol for RSL and monitor the results. After 50 RSL were successfully completed, a retrospective matched-pair analysis with patients who had undergone WLBB during the same period was performed. Overall experience with the RSL protocol was reviewed, along with the occurrence of a seed loss. Processes necessary to re-activate the RSL protocol and prevent future losses were delineated. Radioactive seed localization is associated with decreased rates of re-excision and can be successfully implemented in a public health care system. The authors concluded that RSL is an attractive alternative to WLBB in a high-volume, county-based population. It allows increased efficiency in the operating room and has a low rate of complications. Cautionary measures must be taken to ensure proper seed chain of custody to prevent seed loss.
Jakub et al (2010) noted that WLBB remains the standard method for the surgical excision of non-palpable breast lesions. Because of many of its shortcomings, most important a high microscopic positive margin rate, alternative approaches have been described, including RSL. These investigators highlighted the literature regarding RSL, including safety, the ease of the procedure, billing, and oncologic outcomes. Medline and PubMed were searched using the terms "radioactive seed" and "breast". All peer-reviewed studies were included in this review. The authors concluded that RSL is a promising approach for the resection of non-palpable breast lesions. It is a reliable and safe alternative to WLBB. Radioactive seed localization is at least equivalent compared with WLBB in terms of the ease of the procedure, removing the target lesion, the volume of breast tissue excised, obtaining negative margins, avoiding a second operative intervention, and allowing for simultaneous axillary staging.
McGhan et al (2011) performed a retrospective review of all consecutive RSL procedures performed at a single institution from January 2003 through October 2010. A total of 1,000 RSL breast procedures were performed in 978 patients. Indications for RSL included invasive carcinoma (52 %), in-situ carcinoma (22 %), atypical hyperplasia (11 %), and suspicious percutaneous biopsy findings (15 %). A total of 1,148 seeds were deployed using image guidance, with 76 % placed greater than or equal to 1 day before surgery. Most procedures (86 %) utilized 1 seed. A negative margin was achieved at the first operation in 97 % of patients with invasive carcinoma and 97 % of patients with ductal carcinoma in-situ (DCIS). An additional 9 % of patients with invasive carcinoma and 19 % of patients with DCIS had close (less than or equal to 2 mm) margins, and underwent re-excision. Sentinel lymph node biopsy was successfully performed in 99.8 % of cases. Adverse events included 3 seeds (0.3 %) not deployed correctly on first attempt and 30 seeds (2.6 %) displaced from the breast specimen during excision of the targeted lesion. All seeds were successfully retrieved, with no radiation safety concerns. Local recurrence rates were 0.9 % for invasive breast cancer and 3 % for DCIS after mean follow-up of 33 months. There was no evidence of a learning curve. The authors concluded that RSL is a safe, effective procedure that is easy to learn, with a low incidence of positive/close margins. They stated that RSL should be considered as the method of choice for localization of non-palpable breast lesions. The main drawback of this study was its retrospective, non-randomized design.
Lovrics et al (2011) examined if radio-guided localization surgery (RGL) (radio-guided occult lesion localization [ROLL] and RSL) for non-palpable breast cancer lesions produces lower positive margin rates than standard WLBB surgery. These researchers performed a comprehensive literature review to identify clinical studies using either ROLL or RSL; included studies examined invasive or in-situ breast cancer, and reported pathologically assessed margin status or specimen volume/weight. Two reviewers independently assessed study eligibility and quality and abstracted relevant data on patient and surgical outcomes. Quantitative data analyses were performed. A total of 52 clinical studies on ROLL (n = 46) and RSL (n = 6) were identified; 27 met inclusion criteria: 12 studies compared RGL to WLBB and 15 studies were single cohorts using RGL. A total of 10 studies were included in the quantitative analyses. Data for margin status and re-operation rates from 4 randomized controlled trials (RCT; n = 238) and 6 cohort studies were combined giving a combined odds ratio (OR) of 0.367 and 95 % confidence interval (CI): 0.277 to 0.487 (p < 0.001) for margins status and OR 0.347, 95 % CI: 0.250 to 0.481 (p < 0.001) for re-operation rates. The authors concluded that the findings of this systematic review of RGL versus WLBB demonstrated that RGL technique produces lower positive margins rates and fewer re-operations. While this review was limited by the small size and quality of RCTs, the odds ratios suggested that RGL may be a superior technique to guide surgical resection of non-palpable breast cancers. They stated that these results should be confirmed by larger, multi-centered RCTs.
Langhans et al (2012) stated that the Danish national mammography screening program leads to identification of an increased number of small non-palpable breast tumors, suitable for breast-conserving surgery. Accurate lesion localization is therefore important. The current standard is WLBB and although effective it involves a risk of high rates of positive margin and re-operations. New methods are emerging and RSL seems promising with regards to re-operation rates and logistics. In RSL, a small titanium seed containing radioactive iodine is used to mark the lesion.
The National Comprehensive Cancer Network (NCCN, 2012) clinical practice guideline on breast cancer does not mention the use of RSL.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
CPT codes not covered for indications listed in the CPB:
Radioactive seed localization:
No specific code
Other CPT codes related to the CPB:
+ 77051 - 77059
Other ICD-9 codes related to the CPB:
174.0 - 175.9
Malignant neoplasm of breast
Secondary malignant neoplasm of skin of breast
Secondary malignant neoplasm of breast
Benign neoplasm of breast
Carcinoma in situ of breast
Neoplasm of uncertain behavior of breast
610.0 - 610.8
Benign mammary dysplasias
Lump or mass in breast
793.80 - 793.89
Nonspecific abnormal findings on radiological examination (mammogram) of the breast [breast nodules]
The above policy is based on the following references:
Hernandez L, Connelly PJ, Strickler SA, et al. Are stereotaxic breast biopsies adequate? Surgery. 1994;116(4):610-614; discussion 614-615.
Roe SM, Mathews JA, Burns RP, et al. Stereotactic and ultrasound core needle breast biopsy performed by surgeons. Am J Surg. 1997;174(6):699-703; discussion 703-704.
Yim JH, Barton P, Weber B, et al. Mammographically detected breast cancer, benefits of stereotactic core versus wire localization biopsy. Ann Surg. 1996;223(6):688-697; discussion 697-700.
Bassett L, Winchester DP, Caplan RB, et al. Stereotactic core-needle biopsy of the breast: A report of the Joint Task Force of the American College of Radiology, American College of Surgeons, and College of American Pathologists. CA Cancer J Clin. 1997;47(3):171-190.
Howard J. Using mammography for cancer control: An unrealized potential. CA Cancer J Clin. 1987;33:33-48.
Meyer JE. Large-Needle Core Biopsy: Nonmalignant breast abnormalities evaluated with surgical excision or repeat core biopsy. Radiology. 1998;206(3):717-720.
Franquet T, Cozcolluela R, De Miguel C. Stereotaxic fine-needle aspiration of low-suspicion, nonpalpable breast nodules: Valid alternative to follow-up mammography. Radiology. 1992;183(3):635-637.
Howisey RL, Acheson MB, Rowbotham RK, Morgan A. A comparison of Medicare reimbursement and results for various imaging-guided breast biopsy techniques. Am J Surg. 1997;173(5):395-398.
Winchester DP, Strom EA. Standard for diagnosis and management of ductal carcinoma in-situ (DCIS) of the breast. CA Cancer J Clin. 1998;48(2):108-128.
Parker SH, Burbank FH, Hollander DS. Percutaneous breast biopsy with a new device. Radiology. 1995;197(P):408-412.
Jackman RJ, Burbank F, Parker SH, et al. Atypical ductal hyperplasia diagnosed at stereotactic breast biopsy: Improved reliability with 14-gauge, directional, vacuum-assisted biopsy. Radiology. 1997;204(2):485-488.
D'Angelo PC, Galliano DE, Rosemurgy AS. Stereotactic excisional breast biopsies utilizing the advanced breast biopsy instrumentation system. Am J Surg. 1997;174(3):297-302.
Lindfors KK, Rosenquist CJ. Needle core biopsy guided with mammography: A study of cost-effectiveness. Radiology. 1994;190:217-222.
Center for Medicare and Medicaid Services (CMS). Breast biopsy (CAG-00040N). Decision Memorandum #CAG-00040N. Baltimore, MD: CMS; December 7, 1999. Available at: http://www.hcfa.gov/coverage/8b3-h2.htm. Accessed April 22, 2002.
Medicare Services Advisory Committee (MSAC). Advanced breast biopsy instrumentation. Final Assessment Report. MSAC Application 1001. Canberra, ACT: MSAC; May 1999. Available at: http://www.health.gov.au/msac/pdfs/msac1001.pdf. Accessed April 22, 2002.
Medicare Services Advisory Committee (MSAC). Directional, vacuum-assisted breast biopsy. Final Assessment Report. MSAC Application 1015. Canberra, ACT: MSAC; October 1999. Available at: http://www.health.gov.au/msac/pdfs/msac1015.pdf. Accessed April 22, 2002.
Walsh D, Merlin T, Humenuik V, et al. Clinical practice guidelines for the advanced breast biopsy instrument. ASERNIP-S CPG Report No. 1. Adelaide, SA: Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S); May 2000. Available at: http://www.racs.edu.au/asernips/FinalABBI.pdf. Accessed May 10, 2004.
Medical Services Advisory Committee (MSAC). Advanced breast biopsy instrumentation (ABBI) system for non-palpable breast lesions. Assessment Report. MSAC Application 1037. Canberra, ACT: MSAC; July 2001. Available at: http://www.health.gov.au/msac/pdfs/msac1037.pdf. Accessed May 10, 2004.
Center for Medicare and Medicaid Services (CMS). Percutaneous, image-guided biopsy for palpable lesions. Decision Memorandum #CAG-00074N. Baltimore, MD: CMS; April 12, 2002. Available at: http://www.hcfa.gov/coverage/8b3-jj2.htm. Accessed April 22, 2002.
Liberman L. Percutaneous image-guided core breast biopsy. Radiol Clin North Am. 2002;40(3):483-500, vi.
Klimberg VS. Advances in the diagnosis and excision of breast cancer. Am Surg. 2003;69(1):11-14.
Hoorntje LE, Peeters PH, Mali WP, Borel Rinkes IH. Vacuum-assisted breast biopsy: A critical review. Eur J Cancer. 2003;39(12):1676-1783.
Agency for Healthcare Research and Quality (AHRQ). Diagnosis and management of specific breast abnormalities. Evidence Report/Technology Assessment 33. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2001.
Ellis IO, Humphreys S, Michell M, et al. Best Practice No 179. Guidelines for breast needle core biopsy handling and reporting in breast screening assessment. J Clin Pathol. 2004;57(9):897-902.
Gutierrez A, Taboada J, Apesteguia L, et al. New percutaneous techniques of histological diagnosis of non palpable lesions suspected of breast cancer [summary]. D-05-02. Vitoria-Gasteiz, Spain: Basque Office for Health Technology Assessment, Health Department Basque Government (OSTEBA); 2005.
Alberta Heritage Foundation for Medical Research (AHFMR). Image-guided vacuum-assisted breast biopsy for suspicious, non-palpable breast lesions. Technote TN 50. Edmonton, AB: Alberta Heritage Foundation for Medical Research (AHFMR); 2005. Available at: http://www.ahfmr.ab.ca/publications/. Accessed April 6, 2006.
Weber WP, Zanetti R, Langer I, Mammotome: Less invasive than ABBI with similar accuracy for early breast cancer detection. World J Surg. 2005;29(4):495-499.
Zagorianakou P, Fiaccavento S, Zagorianakou N, et al. FNAC: Its role, limitations and perspective in the preoperative diagnosis of breast cancer. Eur J Gynaecol Oncol. 2005;26(2):143-149.
Altomare V, Guerriero G, Giacomelli L, et al. Management of nonpalpable breast lesions in a modern functional breast unit. Breast Cancer Res Treat. 2005;93(1):85-89.
Hanna WC, Demyttenaere SV, Ferri LE, Fleiszer DM. The use of stereotactic excisional biopsy in the management of invasive breast cancer. World J Surg. 2005;29(11):1490-1494; discussion 1495-1496.
Hatmaker AR, Donahue RM, Tarpley JL, Pearson AS. Cost-effective use of breast biopsy techniques in a Veterans health care system. Am J Surg. 2006;192(5):e37-e41.
Vlastos G, Verkooijen HM. Minimally invasive approaches for diagnosis and treatment of early-stage breast cancer. Oncologist. 2007;12(1):1-10.
Deck W. Vacuum assisted breast biopsy. AETMIS 06-06 RE. Montreal, QC: Agence d'Evaluation des Technologies et des Modes d'Intervention en Sante (AETMIS); 2006.
National Institute for Health and Clinical Excellence (NICE). Image-guided vacuum-assisted excision biopsy of benign breast lesions. Interventional Procedure Guidance 156. London, UK: NICE; 2006.
Hazard HW, Hansen NM. Image-guided procedures for breast masses. Adv Surg. 2007;41:257-272.
Gruber R, Bernt R, Helbich TH. Cost-effectiveness of percutaneous core needle breast biopsy (CNBB) versus open surgical biopsy (OSB) of nonpalpable breast lesions: Metaanalysis and cost evaluation for German-speaking countries. Rofo. 2008;180(2):134-142.
Jackman RJ, Marzoni FA Jr, Rosenberg J. False-negative diagnoses at stereotactic vacuum-assisted needle breast biopsy: Long-term follow-up of 1,280 lesions and review of the literature. AJR Am J Roentgenol. 2009;192(2):341-351.
Raylman RR, Majewski S, Smith MF, et al. The positron emission mammography/tomography breast imaging and biopsy system (PEM/PET): Design, construction and phantom-based measurements. Phys Med Biol. 2008;53(3):637-653.
Ward ST, Shepherd JA, Khalil H. Freehand versus ultrasound-guided core biopsies of the breast: Reducing the burden of repeat biopsies in patients presenting to the breast clinic. Breast. 2010;19(2):105-108.
Szynglarewicz B, Kasprzak P, Kornafel J, et al. Duration time of vacuum-assisted biopsy for nonpalpable breast masses: Comparison between stereotactic and ultrasound-guided procedure. Tumori. 2011;97(4):517-521.
Rao R, Moldrem A, Sarode V, et al. Experience with seed localization for nonpalpable breast lesions in a public health care system. Ann Surg Oncol. 2010;17(12):3241-3246.
Jakub JW, Gray RJ, Degnim AC, et al. Current status of radioactive seed for localization of non palpable breast lesions. Am J Surg. 2010;199(4):522-528.
McGhan LJ, McKeever SC, Pockaj BA, et al. Radioactive seed localization for nonpalpable breast lesions: Review of 1,000 consecutive procedures at a single institution. Ann Surg Oncol. 2011;18(11):3096-3101.
Lovrics PJ, Cornacchi SD, Vora R, et al. Systematic review of radioguided surgery for non-palpable breast cancer. Eur J Surg Oncol. 2011;37(5):388-397.
Langhans L, Vejborg TS, Vejborg I, Kroman N. Marking of non-palpable changes in breast tissue. Ugeskr Laeger. 2012;174(34):1891-1894.
National Comprehensive Cancer Network (NCCN). Breast cancer. NCCN Clinical Practice Guidelines in Oncology. Version. 3.2012. Fort Washington, PA: NCCN; 2012.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.