BlueCross and BlueShield of Montana Medical Policy/Codes
Electrical Impedance Scanning (EIS) of the Breast
Chapter: Medicine: Tests
Current Effective Date: October 25, 2013
Original Effective Date: October 25, 2013
Publish Date: July 25, 2013
Description

Electrical impedance scanning (EIS) of the breast involves the transmission of continuous electricity into the body using either an electrical patch attached to the arm or a hand-held cylinder.  The electrical current travels through the breast where it is then measured at skin level by a probe placed on the breast.  Cancerous tissue conducts electricity differently than normal tissue; therefore, cancerous images may show up on the resulting imaging as a bright white spot.

The TransScan [T-Scan™] 2000 is an EIS device that received approval for marketing from the U.S. Food and Drug Administration (FDA) in 1999, with the following labeled indication:

“The T-Scan 2000 is intended for use as an adjunct to mammography in patients who have equivocal mammographic finding with ACR [American College of Radiology] BI-RADS™ [Breast Imaging-Reporting Data System] categories 3 or 4.  In particular, it is not intended for use in cases with clear mammographic or non-mammographic indications for biopsy.  This device provides the radiologist with additional information to guide a biopsy recommendation.” 

The newer T-Scan™ 2000ED (T-Scan ED) was designed to screen younger women (ages 30-39) for breast cancer in the primary setting.  The device is fundamentally the same as the T-Scan 2000; however, the post-processing software has been altered to maximize the specificity of the test.  It reports a binary (two part) outcome indicating whether or not the woman is at increased risk of cancer at the time of the test (not over her lifetime, not her life-long risk).  It does not replace mammography or other imaging tools, but a risk assessment tool.  The aim of T-Scan 2000ED is to identify approximately five percent of the target population who may be at five times the risk expected for the age group.  It provides a single result for both breasts combined and does not indicate where any questionable lesion is located.  A positive result would have to be followed-up by additional breast imaging. This device was reviewed by the FDA’s Obstetrics and Gynecological Devices Panel on August 29, 2006, which recommended unanimously that it not “be approvable.”.

Research is underway on combining EIS with mammography or tomosynthesis.  The use of EIS to diagnose non-malignant breast disease has also been studied but apparently not with an FDA approved device. The research used a multifrequency electrical impedance tomography device called “MEM” developed at the Russian Academy of Sciences; The MEM device does not appear to be FDA approved.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Electrical impedance scanning (EIS) of the breast is considered experimental, investigational and unproven for all indications.

Policy Guidelines

The CPT category III code (0060T) was discontinued on 12/31/2008, with instructions to use an unlisted CPT code (76499) beginning 1/1/2009.

Rationale

Mammographic abnormalities can be stratified into categories called Breast Imaging-Reporting Data System (BI-RADS) scoring system developed for mammographic evaluation, which reflect the risk of malignancy given the mammographic appearance.  Scores range from 1 to 5 as follows:          

BI-RADS Terminology

BI-RADS Score

Characteristics and Probability of Malignancy

1

No abnormality noted; probability of malignancy is zero. 

2

Benign finding (e.g., fibroadenomas, lipoma).

3

Probably benign finding - Short Follow-up Suggested

This category includes lesions with high probability of being benign, but the radiologist would prefer to establish its stability, and thus repeat mammography at six (6) months is typically recommended. The probability of malignancy is estimated at 2%. 

4

Suspicious abnormality - Biopsy Should Be Considered

These lesions do not have the characteristic morphologies of breast cancer but have a definite probability of being malignant. The radiologist has sufficient concern to urge a biopsy.  The probability of malignancy ranges from 2%–80% in this category. 

5

Highly suggestive of malignancy - The probability of malignancy ranges from 80%–100%. 

Electrical impedance studies (EIS) are used as an adjunct to mammography to improve patient selection for biopsy in patients with equivocal indications, i.e., those designated as a BI-RADS category 3 or 4. There are two potential scenarios:

  • To deselect patients for biopsy, where the key diagnostic statistic is the negative predictive value (NPV). Presumably this role of EIS would be focused on patients with a BI-RADS category 4 lesion, for which biopsy is typically recommended. It may also apply to some patients with BI-RADS category 3 lesion who have been recommended to have a biopsy. The relevant question is whether patients with BI-RADS category 3 or 4 mammographic abnormalities recommended for biopsy that have negative results on EIS can reliably forego breast biopsy. Given the relatively low morbidity and high diagnostic accuracy of the gold standard of breast biopsy coupled with the adverse consequences of missing or delaying diagnosis of breast cancer, the NPV of EIS would have to be extremely high to influence treatment decisions. The NPV is determined partially by the sensitivity of the test; the higher the sensitivity, the higher the NPV. The NPV will also vary according to the prevalence of disease. Among a population of patients with mammographic abnormalities highly suggestive of breast cancer, the NPV will be lower compared to a population of patients with mammographic abnormalities not suggestive of breast cancer. As noted above, the labeled indication for the T-Scan focuses on its use in patients with equivocal mammographic findings.
  • To positively select patients for biopsy, where the positive predictive value (PPV) is the key diagnostic parameter. As noted, management options for patients with BI-RADS category 3 lesions include watchful waiting with repeat mammography. However, positive results of EIS may tip the balance such that biopsy is more definitively recommended.

The T-Scan 2000 was FDA approved through the pre-market approval process, and thus the clinical data to support its safety and effectiveness is available in the FDA summary of safety and effectiveness (3), which is reviewed below. The key pieces of data presented to the FDA were from a multicenter blinded study that intended to test the hypothesis that adjunctive combination of T-Scan with mammography can provide diagnostic accuracy significantly better than mammography alone. The results of this study were reported in terms of sensitivity and specificity instead of PPV and NPV.

The blinded study presented to the FDA consisted of a total of 2,456 patients of whom 882 underwent biopsy and T-Scan. The mammography and T-Scan were performed in a blinded fashion, i.e., each imaging procedure was performed and interpreted without knowledge of the results from any other imaging modality or patient information. A final test set composed of 504 biopsied breasts (179 malignant, 325 benign) was available for re-reading (380 patients were excluded due to unavailability of the original mammogram or incomplete T-Scan image). The test set was re-read and scored “blindly” using T-Scan images alone, using mammograms alone, and using adjunctive combination of mammogram and T-Scan images. Each of the scores was compared against the results of biopsy. Panels of 40–60 patients each were organized for blinded rereading of the T-Scans and mammograms. The panels were composed of patients with both malignant and benign biopsy results, as well as screening patients that did not undergo biopsy. The screening patients were added to the panels so that the readers could not assume that all patients had suspicious mammographic findings. The key subgroup was the 273 patients with equivocal mammographic abnormalities. These included BI-RADS category 3 and some BI-RADS category 4 cases, in which the probability of malignancy was estimated to be between 0 and 50%. Using biopsy results as the gold standard, the sensitivity of the combined mammogram and T-Scan compared to mammogram alone increased from 60% to 82%, while the specificity increased from 41% to 57%. Both of these are statistically significant increases. However, it is unclear from this study if these diagnostic parameters would enable patients with equivocal mammographic abnormalities to forego biopsy. Recalculating the data reveals that the key parameter of the NPV of the combined test is 93%. Therefore, if the decision to forego biopsy was based on a negative result of the combined mammogram and T-Scan, 7% of those with malignant lesions would miss or delay a diagnosis of breast cancer.

As noted, this study included some BI-RADS category 3 or 4 lesions, but it is not specified whether the biopsies were performed in these subjects as part of the study protocol or based on clinical suspicion and/or imaging results. The analysis of diagnostic performance included only those patients who were scheduled for biopsy, which introduces the potential for verification bias. It is uncertain whether these selected cases would be similar to unselected consecutive cases of BI-RADS category 3 or 4 lesions that would not be referred for biopsy in clinical practice. The PPV of adjunctive use of the T-Scan was reported to be 30% among biopsied subjects with BI-RADS category 3 or 4 lesions and an 18% prevalence of malignancy. However, the limitations and potential bias in this analysis prohibit conclusions regarding the effectiveness of using the T-Scan in positively selecting patients for biopsy. For example, it is unknown how many of the original 2,456 patients had equivocal lesions and decided to forego biopsy. This is the critical group to evaluate the role of the T-Scan to positively select those patients for biopsy who would otherwise forego biopsy. While this unselected population and outcome are admittedly more difficult to study, ideally one would like to design a trial in which all patients with equivocal lesions, which would otherwise be referred for follow-up imaging, undergo both T-Scan and biopsy or some other appropriate reference standard such as prolonged clinical follow-up. In this setting, the diagnostic performance and predictive value of T-Scan could be evaluated in the actual intended use.

The “Intended Use” study presented to the FDA consisted of 74 consecutive biopsy cases in which the T-Scan was approved for clinical use in its full intended mode; i.e., the T-Scan was targeted at lesions previously identified by mammography or physical examination, and the T-Scan interpretation was done adjunctively. Of these, there were a total of 36 cases for which biopsy results, mammograms, and T-Scans were available and where the mammographic results were equivocal. The sensitivity of the mammography alone was 66.7% increasing to 93.3% (28 of 30 cases) when the T-Scan was used adjunctively. The corresponding values of specificity were 50% increasing to 83.3% (five of six cases) when the T-Scan was added.  The PPV of adjunctive use of T-Scan was 97% (28 of 29 cases) although the prevalence of malignancy in this subgroup was also very high at 83%. Despite these positive findings, the small number of cases in this study along with the potential bias associated with the fact that analysis was restricted only to half of subjects who received the reference standard makes this evidence insufficient to draw conclusions.

Fuchsjaeger and colleagues further explored the adjunctive role of EIS in 121 patients with 128 BI-RADS 4 lesions identified on mammography. Specifically, the results of EIS were compared with ultrasound (US) as a technique of further classifying benign lesions such that patients could be managed as a BI-RADS 3 lesion with a recommended six-month follow-up instead of biopsy. Therefore, in this setting the most relative statistic is the NPV, which can be used to deselect patients from biopsy. Based on histopathology from a subsequent biopsy, there were 37 malignant lesions and 91 benign lesions. The NPV of EIS was 97.1% vs. 92.0% for US. It is unclear whether this diagnostic performance would be adequate to defer biopsy.

Stojadinovic and colleagues explored a novel role for EIS as a primary screening technique in younger women (less than 40 years) at average risk of breast cancer. (11) Currently, there are no specific screening recommendations other than breast self-examination in this population, in part due to decreased sensitivity of mammograms in imaging dense breast, common in younger populations. EIS is based on the difference in electrical conductivity in benign versus malignant tissue and is not impacted by breast density.  This study included 1,103 women who were undergoing screening with a clinical breast examination and women who were specifically referred for breast biopsy (the reasons for the referral were not stated). A total of 580 of the women were under 40 years old, the targeted age group for primary screening with EIS. Twenty-nine cancers were identified among the entire group of 1,103; six of these were in women under 40. Based on this small number of cancers, the sensitivity and specificity of EIS in women under 40 was 50% and 90%, respectively. It should also be noted that of the 580 in the under 40 group, 132 (23%) presented with palpable breast lesions, and only two of the six identified cancers were nonpalpable, and all cancers were found in women specifically referred for breast biopsy; none were found in the general screening population. As noted by the authors, this is a preliminary study, and further data with longer follow-up are needed.  However, the authors hypothesize that EIS could evolve into a routine part of a physical exam performed in a physician office setting. A positive scan would then prompt further imaging with either a magnetic resonance imaging (MRI) or ultrasound.

An additional search and review of scientific literature conducted through July 20 did not identify any significant new literature that would prompt reconsideration of the policy statement, which remains unchanged.

2010 Update

In 2006, there appears to be a follow-up study to that of Stojadinovic and colleagues. The  results were reported for 1,361 consecutively enrolled asymptomatic women ages 30–39 years (used to measure specificity), and 189 women ages 30–45 years who had a suspicious breast abnormality and were referred for biopsy (used to measure sensitivity). (12) The researchers assumed that none of the women in the first group had breast cancer and, consequently, that any positive EIS results were false positives; no follow-up data were collected on these women. In the second group of women with breast abnormalities, 59.3% were aged 40–45. The specificity in the first group was 95% (assuming that all positive results were incorrect); the specificity in the second group among women with benign breast disease was 80.7%.  The sensitivity in the second group was 38%, but it ranged from 29% among women aged 30–39 to 42% among women aged 40–45. The authors concluded that the relative probability that a woman with a positive EIS result currently has breast cancer is 7.68 and that about one cancer would be detected for every 77 women referred for follow-up. This study has a number of limitations, including the assumption that none of the women in the specificity arm had cancer (the authors argue that this assumption is likely to have little impact on the overall results given the low prevalence of cancer in this population); the age difference between the two groups (and the difference in sensitivity by age, although whether or not this is statistically significant is not reported), and the measurement of sensitivity and specificity in two different populations. The authors themselves conclude that the results are encouraging but that “further large-scale, long-term follow-up studies are required and underway in the intended use populations.” The FDA’s Obstetrics and Gynecological Devices Panel had a number of concerns about the study, and the FDA has not approved the device for this use.”

In a later follow-up, Stojadinivoc and co-workers reported on 1,751 patients in the specificity group and 390 patients (with 87 cancers) in the sensitivity group. (13) The patients were recruited at 22 sites in the United States and seven in Israel. The specificity calculated for the first group (assuming all positive test results were incorrect) was 94.7% (95% CI: 93.7–95.7%). One center had a specificity of 84%, while the others ranged from 89% to 97%. Sensitivity calculated for the second group was 26.4% (95% CI: 17.4–35.4%). The number of cancers at each site was small; the sensitivity per site ranged from 0% to 53%. Combining these results and the assumption that the prevalence of breast cancer in an average-risk group of women 30–39 years of age, the authors estimated that for every 136 women with a positive T-Scan result, one would have cancer.  If all T-Scan-positive women in this age group underwent mammography, it is estimated that about one in 194 women would have cancer (this estimate is lower because of the less than perfect sensitivity of mammography). The authors state that this detection rate is higher than would be found among a randomly selected group of 30- to 39-year old women or among women younger than 40 years of age with an affected first-degree relative (about one cancer detected in every 333 women). The relative probability of cancer in a T-Scan-positive woman is estimated to be 4.95 (95% CI: 3.16–7.14). These calculations apparently do not include the patients in whom T-Scans were attempted but not completed: 14 women in the specificity group and four women in the sensitivity group. Because of technical difficulties, 66 results in the second group were considered unreliable, but the authors argue that these problems might have been corrected if the examiners had not been blinded to the results and, therefore, were unaware of the problems; examiners in the specificity group were not blinded.  The sensitivity of this test remains low, even in a group of women with a deliberately higher prevalence of cancer than would be expected in a screening population.

Further research has also been performed on the characteristics of electromagnetic breast imaging in distinguishing between normal breast tissue and abnormal tissue, and between cancerous and benign abnormal tissue. (14) EIS was one of the three electromagnetic imaging modalities used in women with mammography results rated as BI-RADS category 1 (negative; 53 women) or category 4 (suspicious for malignancy) or 5 (highly suspicious for malignancy; 97 women in “abnormal” group). The focus was on a prospective, quantitative assessment of the contrast in electromagnetic properties between normal and abnormal tissue. EIS results were available for 62 “abnormal” cases and 36 normal controls; EIS data were not available for 19 cases due to technical difficulties and 33 cases due to analytical difficulties (data calibration). EIS was found to help in discrimination between normal and abnormal tissue but “may not aid” in distinguishing between cancer and other abnormal pathological findings. Using results from all three modalities examined (EIS, microwave imaging spectroscopy, and near-infrared spectral tomography) did not substantially improve the ability to identify breast cancer.

In conclusion, the studies identified did not lead to a change in the coverage statement; these technologies were still considered experimental, investigational and unproven.

2013 Update

In 2013, further research was completed by Vrugdenburg and colleagues. The objective of this study aimed to systematically identify and evaluate all the available evidence of safety, effectiveness and diagnostic accuracy for three emerging classes of technology promoted for breast cancer screening and diagnosis: Digital infrared thermal imaging (DITI), electrical impedance scanning (EIS) and elastography. A systematic search of seven biomedical databases (EMBASE, PubMed, Web of Science, CRD, CINAHL, Cochrane Library, and Current Contents Connect) was conducted through March 2011, along with a manual search of reference lists from relevant studies. The principal outcome measures were safety, effectiveness, and diagnostic accuracy. Data were extracted using a standardized form, and validated for accuracy by the secondary authors. Study quality was appraised using the quality assessment of diagnostic accuracy studies tool, while heterogeneity was assessed using forest plots, Cooks' distance and standardized residual scatter plots, and I (2) statistics. From 6,808 search results, 267 full-text articles were assessed, of which 60 satisfied the inclusion criteria. No effectiveness studies were identified. Only one EIS screening accuracy study was identified, while all other studies involved symptomatic populations. Significant heterogeneity was present among all device classes, limiting the potential for meta-analyses. Sensitivity and specificity varied greatly for DITI (Sens 0.25-0.97, Spec 0.12-0.85), EIS (Sens 0.26-0.98, Spec 0.08-0.81) and ultrasound elastography (Sens 0.35-1.00, Spec 0.21-0.99). It is concluded that there is currently insufficient evidence to recommend the use of these technologies for breast cancer screening. Moreover, the high level of heterogeneity among studies of symptomatic women limits inferences that may be drawn regarding their use as diagnostic tools. Future research employing standardized imaging, research and reporting methods is required. (15)

A search of peer reviewed literature was conducted via Medline through July 2013. The clinical trial identified did not lead to a change in the coverage statement; these technologies are still considered experimental, investigational and unproven.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Experimental, investigational and unproven for all diagnosis.

ICD-10 Codes

Experimental, investigational and unproven for all diagnosis.

Procedural Codes: 76499
References
  1. Kao TJ, Boverman G, Isaacson D et al. Regional admittivity spectra with tomosynthesis images for breast cancer detection. Conf Proc IEEE Eng Med Biol Soc 2007; 2007:4142-5.
  2. Trokhanova OV, Okhapkin MB, Korjenevsky AV. Dual-frequency electrical impedance mammography for the diagnosis of non-malignant breast disease. Physiol Meas 2008; 29(6):S331-44.
  3. U.S. Food and Drug Administration. Summary of safety and effectiveness data: T-Scan 2000. April 1999. Available online at http://www.fda.gov/cdrh/pdf/p970033b.pdf . Last accessed October 2008.
  4. Perlet C, Kessler M, Lenington S et al. Electrical impedance measurement of the breast: effect of hormonal changes associated with the menstrual cycle. Eur Radiol 2000; 10(10):1550-4.
  5. Martin G, Martin R, Brieva MJ et al. Electrical impedance scanning in breast cancer imaging: correlation with mammographic and histologic diagnosis. Eur Radiol 2002; 12(6):1471-8.
  6. Malich A, Bohm T, Facius M et al. Additional value of electrical impedance scanning: experience of 240 histologically proven breast lesions. Eur J Cancer 2001; 37(18):2324-30.
  7. Wersebe A, Siegmann K, Krainick U et al. Diagnostic potential of targeted electrical impedance scanning in classifying suspicious breast lesions. Invest Radiol 2002; 37(2):65-72.
  8. Malich A, Boehm T, Facius M et al. Differentiation of mammographically suspicious lesions: evaluation of breast ultrasound, MRI mammography and electrical impedance scanning as adjunctive technologies in breast cancer detection. Clin Radiol 2001; 56(4):278-83.
  9. Malich A, Fritsch T, Anderson R et al. Electrical impedance scanning for classifying suspicious breast lesions: first results. Eur Radiol 2000; 10(10):1555-61.
  10. Fuchsjaeger MH, Flory D, Reiner CS et al. The negative predictive value of electrical impedance scanning in BI-RADS category IV breast lesions. Invest Radiol 2005; 40(7):478-85.
  11. Stojadinovic A, Nissan A, Gallimidi Z et al. Electrical impedance scanning for the early detection of breast cancer in young women: preliminary results of a multicenter prospective clinical trial. J Clin Oncol 2005; 23(12):2703-15.
  12. Stojadinovic A, Moskovitz O, Gallimidi Z et al. Prospective study of electrical impedance scanning for identifying young women at risk of breast cancer. Breast Cancer Res Treat 2006; 97(2):179-89.
  13. Stojadinovic A, Nissan A, Shriver CD et al. Electrical impedance scanning as a new breast cancer risk stratification tool for young women. J Surg Oncol 2008; 97(2):112-20.
  14. Poplack SP, Tosteson TD, Wells WA et al. Electromagnetic breast imaging: results of a pilot study in women with abnormal mammograms. Radiology 2007; 243(2):350-9.
  15. Vreugdenburg TD et al., A systematic review of elastography, electrical impedance scanning and digital infrared thermography for breast cancer screening and diagnosis, Breast Cancer Res Treat (2013 Feb) 137( 3):665-76.  
  16. FDA - Mirabel Medical Systems, Inc. T-Scan™ 2000ED (P050003) Draft Discussion Questions.  Federal Drug Administration - Obstetrics and Gynecology Devices Panel (2006 August 29).  Available at http://www.fda.gov .  (Accessed on - 2010 March 12).
  17. Cheng, Z., Xiuzhen, D., et al.  Breast cancer detection based on multi-frequency EIS measurement.  Conference Proceedings - IEEE (Institute of Electrical and Electronics Engineers) Engineering in Medicine and Biology Society (2007) 2007:4158-60.
  18. Wang, K., Wang, T., et al.  Electrical impedance scanning in breast tumor imaging: correlation with the growth pattern of lesion.  Chinese Medical Journal (English) (2009 July 5) 122(13):1501-6.
  19. Ji, Z., Dong, X., et al.  Novel electrode-skin interface for breast electrical impedance scanning.  Medical and Biological Engineering and Computing (2009 October) 47(10):1045-52.
  20. Electrical Impedance scanning of The Breast, Chicago, Illinois: Blue Cross Blue Shield Association, Medical Policy Reference Manual (Archived December 2009) Medicine 2.01.63.
History
July 2013  New 2013 BCBSMT medical policy.  Electrical impedance scanning (EIS) of the breast is considered experimental, investigational and unproven for all indications.   
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Electrical Impedance Scanning (EIS) of the Breast