Description

Ductal lavage is a minimally invasive procedure. A small amount of nipple aspirate fluid (NAF) is elicited to locate fluid-yielding ducts for lavage. Next, a microcatheter is inserted into each NAF-yielding duct through its natural opening on the nipple surface. Saline is infused through the microcatheter into the duct to collect epithelial cells. The ductal fluid is then withdrawn through the catheter. The fluid is then analyzed microscopically for cytological abnormalities.

Fiberoptic ductoscopy also referred to as mammary (breast) ductoscopy is a procedure that involves enlargement of the duct at the nipple with small metal wires. A ductoscope which is a small tube with a camera attached is passed into the duct and advanced into the breast. Water may be injected through the scope and examined and/or a very thin wire probe may be passed up to several inches into beast to sample any abnormalities that might be found.

Breast ductal lavage and fiberoptic ductoscopy are not to be used as a routine breast cancer diagnostic tool.

Criteria

Breast Ductal Lavage

Breast ductal lavage may be considered medically necessary when non-lactational nipple discharge is too low to permit adequate cytological analysis.:

Breast ductal lavage in combination with ductoscopy for the evaluation of women with ipsilateral breast cancer is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Breast ductal lavagefor the purpose of breast cancer screening, breast cancer risk-assessment and for all other indications is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Fiberoptic Ductoscopy

Fiberoptic ductoscopy may be considered medically necessary:

• When combined with cytology testing for diagnosing intra-ductal lesions in women with non-lactational sporadic nipple discharge accompanied by documented positive cytology,or
• As a guide for resection of known breast intra ductal cancer.

Fiberoptic ductoscopy is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature when used for breast cancer screening and all other indications.

Procedure Codes

Diagnosis Codes

NA

Professional Statements and Societal Positions Guidelines

NA

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Adopted for ND