Breast Radiology

For Members:

  • What is Breast Screening?
    • Breast Screening is of utmost importance in early diagnosis of the cancers and timely treatments.
    • The earlier the cancer is diagnosed, the better are the outcomes in terms of survival and quality of life.
  • The most common types of screenings are:
    • Self-Exam
    • Mammograms
    • Ultrasound
  • Screening Recommendations:
    • 40 to 44: Have the choice to start yearly mammogram.
    • 45 to 54: Get yearly mammograms.
    • 55 and older: Either a mammogram every other year or continue getting yearly mammograms.
  • Risk Factors of Breast cancers:
    • Age: 50 or above.
    • Family history: Having a 1st-degree relative (mother, sister, and daughter).
    • Personal history: Having a situ or invasive breast previously.
    • Gynecologic history: Early menstruations, late menopause, or late first pregnancy.
    • Breast changes: History of a lesion/s that required a biopsy increases risk slightly.
    • Oral contraceptives Use: Oral contraceptive use increases risk very slightly.
    • Hormone therapy: Postmenopausal hormone (estrogen plus a progestin).
    • Radiation therapy: Exposure to radiation therapy before age 30 increases risk.
    • Diet: Diet may contribute to development or growth of breast cancers e.g. high in fats.
    • Obesity: Obese postmenopausal women are at increased risk).
    • Lifestyle factors: Smoking and alcohol.


1- What is Breast Self-Exam?

Self-Exam can be performed in front of large mirror in a well-lit room in your home. Ask your physician to explain how to perform the exam. It is very simple, cost effective, and easy to identify any lump or cyst and identify any abnormality in the breast. It is recommended to perform breast exam every month after menstrual cycle.

2- What is Diagnostic mammography?


Mammography uses special X-ray images to spot abnormal growths or changes in breast tissue.

Using a digital X-ray machine made especially for breast tissue, a technician takes pictures from at least two angles to make a set of images for each of your breasts. Diagnostic mammography is performed to evaluate patients who have signs and/or symptoms of breast abnormalities or disease.


  • Abnormality found on screening mammogram.
  • Short interval follow up of probably benign but abnormal mammogram.
  • Patient/physician identified breast lump.
  • Focal breast pain/tenderness.
  • Suspected Abscess.
  • Spontaneous nipple discharge.
  • New nipple changes (e.g. inversion).

3- What is the Breast ultrasound?


A breast ultrasound is a painless procedure that uses sound waves to make images of the inside of your breast. The sound waves bounce off surfaces in your body, and the “echoes” are recorded to make video or image. A common indication for breast ultrasound is evaluation of an abnormal finding observed on mammography, to decide if further investigation or intervention is required or not based on the breast density. The breast density will be reported by categories of BI-RADS (Table-1).


  • Palpable lump; axillary adenopathy.
  • First diagnostic approach for clinical abnormalities under 40 and in pregnant or lactating women (due to density of the breast tissue).
  • Suspicious abnormalities on mammography or breast MRI.
  • Suspicious nipple discharge.
  • Recent nipple inversion.
  • Skin retraction.
  • Breast inflammation; abnormalities in the area of the surgical scar after breast conserving surgery or mastectomy (surgical removal of Breast/s).
  • Abnormalities in the presence of breast implants.
  • Screening high-risk women (family history), especially when MRI is not performed.
  • Location & Breast Region based staging of a known breast cancer, when MRI is not performed.
  • Guidance for percutaneous interventions (needle biopsy, pre-surgical localization, fluid collection drainage).
  • Monitoring patients with breast cancer receiving initial therapy, when MRI is not performed.
  • Supplemental screening after mammography for women aged 40–74 with dense breasts.
BIRADS Score Likelihood of Cancer
BIRADS 0 Incomplete: Need additional Imaging Evaluation
BIRADS 1 Negative (no malignancy)
BIRADS 2 Benign (no malignancy)
BIRADS 3 Probably benign (very low possibility of malignancy)
BIRADS 4 Suspicious (possibility of malignancy)
BIRADS 4A Finding needing intervention with a low suspicion for malignancy
BIRADS 4B Lesions with an intermediate suspicion of malignancy
BIRADS 4C Findings of moderate concern, but not classic for malignancy
BIRADS 5 Highly Suggestive of Malignancy
BIRADS 6 Known Biopsy Proven Malignancy



For Healthcare Providers:



  • All Breast Screening (Mammography & Ultrasounds) will require pre-approval from Nextcare.
  • Diagnostic mammography will not be covered for screening purpose unless it is covered under well-being or screening benefits.
  • Diagnostic mammography will be covered for diagnosed conditions and/o for members with signs and symptoms only.
  • Claims will not be approved when both screening and diagnostic mammography are billed together for the same patient on the same day.
  • Screening mammography will be approved only if ‘Preventive screening’ Or ‘Routine Health Check Up’ is covered, otherwise diagnostic screening codes should be used if the member is symptomatic.
  • Ultrasound can determine whether the lesion is a simple cyst or skin lesion requiring any intervention or not and if a suspected malignancy requires a biopsy or not.
  • Only Breast Ultrasound will be approved without mammography when:
  • If the member is under age 40.
  • If breast problems/symptoms are observed while pregnant.
  • If there is a cyst that needs to be drained.
Diagnostic mammography
CPT Description
77055 Mammography; unilateral (77055 has been deleted. To report, use 77065).
77056 Mammography; bilateral (77056 has been deleted. To report, use 77066).
77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.
77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.
77061 Digital breast tomosynthesis; unilateral
77062 Digital breast tomosynthesis; bilateral
77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed.
G0206 Diagnostic mammography, producing direct digital image.
Breast ultrasound
CPT Description
76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete.
76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; Limited