Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 08/21/2003	Title: Breast Duct Lavage
Revision Date: 02/05/2014	Document: BI002:00
CPT Code(s): 19499
Public Statement
Breast duct lavage is considered investigational. QualChoice does not cover breast duct lavage as a screening tool to detect women at high risk for breast cancer. This test has not established a valid role in detection, prevention or treatment of breast cancer. Investigational and experimental treatments are not covered benefits.
Medical Statement
The use of cytological examination of breast fluid alone, whether by ductal lavage, fine needle nipple aspiration, or the noninvasive HALO Breast Pap Test system, is considered experimental and investigational and is not covered. A national Cancer Institute report updated in April 2013 states that use of ductal lavage as a screening or diagnostic tool remains investigational, because ductal lavage screening has not been compared to mammography and there is no evidence of efficacy or mortality reduction. The National Comprehensive Cancer Network guideline on breast cancer screening and diagnosis states that current evidence does not support the routine use of ductal lavage as a screening modality for breast cancer. Codes Used In This BI: 19499 Unlisted procedure, breast
Reference
1. American Society of Breast Surgeons. Ductal cell-based risk assessment statement. May 2007. 2. National Cancer Institute. Breast Cancer Screening PDQ. April 2013. Accessed on 19 December 2013 at: http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/AllPages 3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Breast cancer screening and diagnosis. V1.2013.
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.

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