Program Operations Manual System (POMS)
TN 61 (10-23)
DI 23022.125 Breast Cancer – with Distant Metastases or Recurrent
COMPASSIONATE ALLOWANCES INFORMATION
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BREAST
CANCER - WITH DISTANT
METASTASES OR RECURRENT
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ALTERNATE NAMES
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Breast Carcinoma (Stage IV); Metastatic Breast Carcinoma; Metastatic Breast Cancer;
Ductal Carcinoma of the Breast (Stage IV); Metastatic Ductal Carcinoma; Metastatic
Ductal Cancer; Lobular Carcinoma of the Breast Stage (IV); Metastatic Lobular Cancer
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DESCRIPTION
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Breast Cancer forms in tissues of the breast, usually the ducts and lobules. It occurs in both
men and women, although male breast cancer is rare. Individuals with breast cancer
meeting the criteria under the listings have a poor prognosis.
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DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND
ICD-9-CM/ICD-10-CM
CODING
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Diagnostic testing: The diagnosis of Breast Cancer is made by clinical breast examination and imaging
tests, such as mammogram, ultrasound, and MRI. A needle or incisional biopsy confirms
the diagnosis.
Physical findings:
Individuals with listing level severity of Breast Cancer may present with:
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A breast lump or changes in breast size or shape;
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Skin dimpling or skin changes (e.g. Thickening, swelling or redness);
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Nipple inversion or other nipple abnormalities (e.g. ulceration, retraction, or spontaneous
bloody discharge);
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Axillary lump or contour changes;
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Signs of metastatic spread may include:
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Localizing neurologic signs;
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Altered cognitive function or headache.
ICD-9: 174.9
ICD-10: C79.81
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PROGRESSION
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The 5-year survival rate for breast cancers that have spread to other parts of the
body tend to have a poor prognosis. The 5-year survival rate for individuals with
stage IV breast cancer when appropriately treated is about 20%.
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TREATMENT
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Treatment may include surgery, chemotherapy, radiation, and hormone therapy.
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SUGGESTED PROGRAMMATIC
ASSESSMENT* |
Suggested MER for Evaluation:
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Clinical history and examination that describes the diagnostic features of the impairment;
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Summaries of hospitalization and medical reports if we cannot get a pathology report
or operative note. These summaries should provide us with details of the findings
at surgery and, whenever appropriate, the pathological findings; and
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In place of an operative note, a pathology report indicating positive margins may
be substituted.
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Suggested Listings for
Evaluation: |
DETERMINATION |
LISTING
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REMARKS |
Meets |
13.10 A, B, or C |
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Equals |
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* Adjudicators may, at their discretion, use the Medical Evidence of Record or the
listings suggested to evaluate the claim. However, the decision to allow or deny the
claim rests with the adjudicator
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