Medical Policy

Effective Date:04/17/2002 Title:Fiberoptic Ductoscopy
Revision Date:03/21/2005 Document:BI098:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Fiberoptic Ductoscopy, a procedure to allow a physician to view the inside of the ducts of the female breast, is not covered. There is, as yet, inadequate evidence to establish this procedure as a valuable, established step in the diagnosis and/or treatment of breast cancer.
Medical Statement

Fiberoptic ductoscopy is considered experimental and investigational and is not eligible for coverage.  [These procedures will be denied as a contract exclusion as experimental and investigational.]

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Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.