Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that 
breast sonography may be indicated for conditions such as: 
 
    Guidance for breast interventional procedures 
    Assessment of implant related problems 
    Radiation treatment planning 
    Initial evaluation of palpable masses in women under 30 
    In lactating and pregnant women 
    Assessment of palpable abnormalities on physical exam 
    Assessment to distinguish simple mastitis from abscess formation 
    Assessment of any mass to determine whether it is suitable for percutaneous intervention (core biopsy, for 
instance) 
    Assess stability of a sonographically visible mass that is mammographically invisible 
    Non-palpable masses, detected by mammography, to differentiate cysts from solid lesions 
    Palpable masses, if needle aspiration is not performed 
    Symptomatic, possible ruptured silicone breast prosthesis when an MRI is not possible 
    Calcifications to determine if an invasive component exists that would be amenable to core biopsy when 
supported by additional clinical indications. 
 
Breast ultrasonography should not be routinely used along with diagnostic mammography. Ultrasonography 
may be indicated in addition to diagnostic mammography for the evaluation of some ambiguous 
mammographic or palpable masses or focal asymmetric densities that may represent or mask a mass. 
 
Breast ultrasonography may be performed, in some cases, without having a diagnostic mammography first. 
However, an order from the treating physician for the ultrasonography is required. For example: a 22-year-old 
female presents with a painful breast lump. An ultrasound is performed and documents a large simple cyst, 
which subsequently is aspirated and resolved without the need for a prior diagnostic mammography. 
 
A treating provider's (physician or qualified non-physician practitioner) order is required for breast ultrasound. 
This requirement is not applicable to hospital based radiologists for inpatient or outpatient breast ultrasound. 
 
Breast sonography should be performed under the general supervision of a physician qualified in breast ultrasonography. 
 
Breast MRI 
 
Breast MRI studies are to be used very selectively. The modality should be restricted to: 
 
    cases where diagnosis is inconclusive, even after standard work-up; 
    evaluation of the post-operative patient when scar tissue cannot be differentiated from tumors; 
    patients with positive axillary nodes but no known primary; 
    patients with rupture of a breast implant; or 
    determination of the extent of disease in patients with known malignancy, prior to treatment (to assure 
confinement to one segment of the breast). 
 
Breast MRI should be performed under the general supervision of a physician qualified in magnetic resonance 
imaging. 
 
A treating provider's (physician or qualified non-physician practitioner) order is required for breast MRI. This 
requirement is not applicable to hospital based radiologists for inpatient or outpatient breast MRI. 
 
Ductogram (Galactogram) 
 
Ductography is useful as an aid in diagnosing the cause of an abnormal nipple discharge and is valuable in 
diagnosing intraductal papillomas. 
 
Ductography should be performed under the personal supervision of a physician qualified in ductography. 
 
A treating provider's (physician or qualified non-physician practitioner) referral is required for ductography. 
This requirement is not applicable to hospital based radiologists for an inpatient or outpatient ductogram 
(galactogram). 
 
Limitations: 
 
    There is no separate transportation cost allowed for other breast imaging procedures. To receive 
transportation payments, the approved portable x-ray supplier must also meet the certification requirements of 
Section 354 of the Public Health Service Act. 
 
You can find these rules in Local Coverage Determination (LCD) Breast Imaging: Breast Echography 
(Sonography)/Breast MRI/Ductography (L33585). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.