CurrentAetnaPolicy 0105

Magnetic Resonance Imaging (MRI) of the Breast

Defines Aetna's medical necessity, experimental/investigational exclusions, and coding guidance for magnetic resonance imaging of the breast for members and providers.

Policy Summary

PayerAetna

PolicyMagnetic Resonance Imaging (MRI) of the Breast

Policy CodePolicy 0105

Change TypeNo material change (routine review)

Effective DateMar 22, 1996

Next Review DateJan 25, 2024

Key ActionProvide documentation of prior conventional imaging and clinical rationale when requesting prior authorization for surveillance or screening breast MRI.

SourceLink

05/12/2023Last review

03/22/1996Policy effective (orig)

20-25%Lifetime risk threshold

Every 2 yrsImplant rupture interval

0697T/0698T/C8937Not covered examples

~145Estimated refs

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Coverage Criteria and Clinical Considerations

inv-01: Medically necessary indications

Aetna considers breast MRI medically necessary when ANY of the listed specific clinical circumstances are met (with or without contrast), provided recent conventional mammography and/or sonography within the past year when indicated:

Primary medically necessary indications: For individuals with prior chest radiation between ages 10–30; to assess tumor location/size/extent before or after neoadjuvant chemotherapy for locally advanced breast cancer; to detect symptomatic implant rupture; to detect suspected local recurrence after mastectomy with implant reconstruction; to detect local recurrence when mammography/ultrasound limited by dense breasts or surgical scar; to assess extent of residual cancer after incomplete lumpectomy when re-excision is planned and breast conservation is desired; to guide localization/biopsy of lesions seen only on contrast-enhanced MRI; to localize primary occult cancer in individuals with adenocarcinoma in an axillary node without a breast primary on exam or conventional imaging; to map extent of primary tumors and identify multifocal/multicentric disease (including invasive lobular carcinoma, Paget's disease, phyllodes tumor preoperatively when biopsy-proven); to perform contralateral breast examination in patients with multifocal/multicentric disease, before neoadjuvant systemic therapy, adenocarcinoma in axillary node without an identified primary, invasive lobular carcinoma, or Paget's disease; for lesion characterization (eg, nipple retraction or unilateral bloody/clear nipple drainage) when mammography/ultrasound and physical exam are inconclusive; after breast conservation therapy when suspicious clinical or imaging findings remain indeterminate after complete mammographic and sonographic evaluations; for evaluation of inconclusive or conflicting findings on mammography or ultrasound that are not a discrete palpable mass; as an adjunct to mammography for screening in women at high genetic risk (specific gene carriers or lifetime risk 20–25% or greater using standard models); to detect intra-capsular (silent) silicone implant rupture (screening no more often than every 2 years); and to follow-up MRI-detected BI-RADS 3 lesions every 6 months for up to two years (MRI not medically necessary for initial evaluation of BI-RADS 3).

inv-02: Experimental / Investigational (Not covered)

Aetna considers the following indications experimental/investigational (not an all-inclusive list):

Experimental/Investigational indications: Dermatomyositis as an indication for breast cancer screening; quantitative measurements of breast density by MRI; screening persons with APC or GALNT12 mutations; surveillance of asymptomatic individuals after completion of primary therapy who are not at high genetic risk; use of MRI to confirm implant rupture when ultrasound already demonstrates rupture (especially older implants); diagnosis of fat necrosis after breast reduction surgery; differentiating benign from malignant disease for clustered microcalcifications; differentiating cysts from solid lesions when ultrasound is appropriate; pre-biopsy MRI intended primarily to reduce benign surgical biopsies; use of MRI to evaluate BI-RADS 4 or 5 lesions in lieu of biopsy (BI-RADS 4/5 lesions should be biopsied); routine evaluation of LCIS, DCIS, or ADH by MRI; evaluation of retro-pectoral fat grafting post-reduction; intra-operative MRI for quantifying tumor deformation and immediate residual tumor detection; early prediction of chemotherapy response for regimen selection; screening average-risk women; screening BRCA-positive men; screening individuals with MUTYH mutation; quantitative MRI approaches for predicting recurrence risk or tissue-composition quantitative MR codes (eg, 0697T/0698T).

inv-03: Clinical coverage considerations

Clinical-use considerations derived from cited evidence and guideline statements

Pre-operative MRI in newly diagnosed breast cancer: Consider MRI to evaluate extent of disease or screen the contralateral breast in selected patients (eg, when conventional imaging is indeterminate or to assess multifocality), but routine pre-operative MRI for all early-stage patients is not supported; MRI often detects additional lesions yet has not consistently been shown to improve outcomes and may increase unnecessary more-radical surgery.

Supported by Lehman et al (2007), Houssami and Hayes (2009), Plana et al (2012).

MRI for contralateral screening at diagnosis: MRI can detect occult contralateral cancers in a small proportion (~3–5%), and may be considered at initial diagnosis in selected patients (NCCN category 2B); pathologic confirmation of MRI-detected lesions is recommended before changing surgical management.

Lehman et al (2007); Plana et al (2012).

MRI for routine surveillance after primary treatment: Routine MRI for asymptomatic surveillance after primary therapy is not recommended; follow-up should emphasize history, physical exam, and mammography at recommended intervals.

inv-04: Evidence summaries and implied coverage considerations

Extracted evidence summaries and implied coverage considerations from the literature in this section:

Fat necrosis: MRI demonstrates variable findings for post-operative fat necrosis and may lower specificity due to enhancing granulation tissue; mammography and ultrasound remain important diagnostic tools and many lesions require biopsy for definitive diagnosis.

Nipple discharge: For bloody or clear nipple discharge obtain mammography and ultrasound first; MRI (including MR ductography) is not routinely recommended and should only be used when conventional imaging is inconclusive and MR-guided biopsy capability is available.

Intra-operative supine MRI can quantify tumor deformation between prone and supine positions and may help evaluate residual tumor immediately after breast-conserving surgery, but findings are preliminary and need validation.

Quantitative MRI / radiomics: Computer-extracted MRI phenotypes (radiomics) show correlations with multi-gene recurrence scores and may aid risk stratification, but these techniques are investigational pending further validation.

inv-05: Coverage-related evidence summaries

Coverage considerations and evidence summary

High-risk screening indication: Contrast-enhanced MRI is recommended as an adjunct to mammography for screening women at high genetic risk (lifetime risk >=20–25% per validated models) and for certain pathogenic variant carriers; MRI detects smaller, node-negative cancers but a mortality benefit has not been demonstrated.lifetime risk >=20-25%

ACS/NCCN guidance referenced.

Routine follow-up/surveillance after invasive breast cancer or DCIS: NCCN Imaging Appropriate Use Criteria state breast MRI with contrast is not indicated for routine follow-up/surveillance in invasive breast cancer or DCIS; MRI may be considered selectively.

Abbreviated MRI (abMRI): abMRI protocols show comparable sensitivity and specificity to full-protocol MRI in small studies with much shorter acquisition times (reported 2.8–8.5 mins), and promising cancer detection rates, but evidence is very low and requires larger prospective validation before routine adoption.

Investigational/limited evidence.

inv-06: Covered with criteria / Conditional recommendations

Coverage stance and conditional recommendations drawn from cited guidance and studies

MRI screening for certain gene mutation carriers: Contrast-enhanced MRI screening is recommended starting at age 40 for carriers of specific gene variants per NCCN guidance; documentation of carrier status is required and benefit in mortality reduction is unproven.age >=40

MRI for atypia/LCIS/ADH: Consider annual MRI screening for individuals with ADH, LCIS, or ALH when residual lifetime risk is >=20% using validated risk models (eg, Tyrer-Cuzick); evidence supports consideration rather than universal recommendation.RLR >= 20%

Dense breasts and average/intermediate risk: Routine adjunctive MRI for asymptomatic women with dense breasts and no other risk factors is not recommended; mammography remains the primary screening modality per ACOG and other groups.

For BI-RADS 3 lesions originally detected by MRI, Aetna considers MRI follow-up every 6 months for up to two years to be medically necessary. However, MRI is not considered medically necessary for the initial evaluation of a BI-RADS 3 lesion; initial assessment should rely on the diagnostic pathway that produced the BI-RADS 3 classification and follow standard imaging surveillance as described above. (Follow-up that converts to BI-RADS 1–2 reverts to routine screening based on the individual’s risk profile.)

Routine use of breast MRI for asymptomatic surveillance after completion of primary therapy is not recommended. ASCO guideline updates state that regular history, physical examination and mammography are the recommended follow-up approach and that advanced imaging including MRI is not recommended for routine follow-up in otherwise asymptomatic patients without specific findings. Requests for surveillance MRI should document clinical indications and prior conventional imaging.

MRI is not routinely recommended for the evaluation of nipple discharge. Initial workup of bloody or clear nipple discharge should include mammography and ultrasound and, in most cases, pathologic management (duct excision) when indicated. Where MRI (including MR ductography) is used, it should be performed only after conventional imaging is inconclusive and in locations with MR-guided biopsy capability, since MRI has significant false-positive rates and a negative MRI does not reliably exclude disease.

NCCN Imaging Appropriate Use Criteria indicate that breast MRI with contrast is not indicated for routine follow-up or surveillance of patients with invasive breast cancer or ductal carcinoma in situ (DCIS). Routine surveillance after primary therapy should rely on clinical exam and mammography unless there is a specific, documented indication for MRI.

Annual MRI screening is not supported for women at average or intermediate risk. Major guideline reviews note that although MRI has higher sensitivity than mammography in high-risk populations, there are insufficient data demonstrating a mortality benefit from routine annual MRI in average- or intermediate-risk groups (for example, women with atypical hyperplasia or LCIS without an elevated lifetime risk). MRI screening is generally reserved for those with an estimated lifetime breast cancer risk of 20–25% or greater calculated with standard models.

This Clinical Policy Bulletin is provided for informational purposes to assist in administering plan benefits and does not constitute a contract or guarantee of coverage. Benefit determination for an individual member depends on the terms of the member’s benefit plan and may vary by contract; providers should verify plan-specific coverage and prior authorization requirements.

Aetna provides a list of breast MRI indications that are considered not medically necessary or experimental/investigational in this bulletin. Examples include quantitative MR tissue-composition/density measurements and certain CAD/quantitative codes (listed as not covered), screening average-risk individuals, routine surveillance in asymptomatic post-treatment patients who are not high genetic risk, and other uses enumerated in the Experimental/Investigational section. See the Not Covered / Experimental section for the full list.

Routine pre-operative breast MRI for the typical patient with newly diagnosed early-stage breast cancer is not indicated. Systematic reviews and guideline statements report that pre-operative MRI frequently detects additional foci but has not been shown to improve surgical outcomes or reduce re-excision rates and may lead to more extensive surgery without proven benefit. MRI may be considered selectively when conventional imaging is indeterminate or when additional sensitive assessment of extent or contralateral disease is needed, but pathologic confirmation is recommended before altering surgical management.

MRI should not routinely replace duct excision or established surgical management for pathologic nipple discharge. A negative MRI does not preclude disease; management of pathologic nipple discharge commonly requires duct excision, and MRI (including MR ductography) is reserved for selected cases when conventional imaging is inconclusive and MR-guided biopsy is available.

There are insufficient data to support annual MRI screening for women at average or intermediate risk, including those with atypical hyperplasia or lobular neoplasia (LCIS/ALH), unless their estimated residual lifetime risk meets the high-risk threshold. Major guideline reviews conclude MRI screening should be reserved for individuals with an estimated lifetime breast cancer risk of 20–25% or greater calculated by validated models.

Annual MRI screening is considered unsupported for average- or intermediate-risk women, including those with atypia who do not have an elevated lifetime risk. Guidelines from major groups recommend MRI surveillance primarily for high-risk populations (lifetime risk ≥ 20–25%) rather than routine annual use in these lower-risk cohorts.

Covered MRI Indications and Use Cases

inv-61: Covered MRI indications

Covered MRI indications (diagnostic, staging, high-risk screening adjunct, implant evaluation, lesion follow-up).

Diagnostic and staging indications: Includes preoperative mapping of tumor extent and identification of multifocal/multicentric disease; assessment before and after neoadjuvant chemotherapy; localization of occult primary in patients with adenocarcinoma in axillary node without identifiable breast primary; evaluation of invasive lobular carcinoma and Paget's disease; detection of suspected local recurrence after mastectomy with implant reconstruction; evaluation when mammography/US limited by dense breasts or scar; guidance for MR-only lesion biopsy localization; lesion characterization when other imaging is inconclusive; preoperative assessment of biopsy-proven phyllodes tumor.

High-risk screening adjunct and implant evaluation: Adjunct screening MRI for women at high genetic risk (specified gene carriers or lifetime risk 20–25% or greater per standard models) with mammography within the past year when indicated; detection of intra-capsular (silent) silicone implant rupture (screening not more often than every 2 years); follow-up of MRI-detected BI-RADS 3 lesions every 6 months for up to 2 years.

inv-62: Selected pre-operative staging and contralateral screening at initial diagnosis

CPT, HCPCS and ICD-10 Codes

Provider Requirements, Prior Authorization, and Documentation

Billing Rule

Coverage Contingent on Criteria

Certain breast MRI and MR-guided biopsy/localization CPT and HCPCS codes are covered only when the policy's selection criteria are met. Requests for quantitative MR tissue composition codes (0697T, 0698T) and CAD HCPCS (C8937) are considered experimental/not covered for indications in this Clinical Policy Bulletin.

Covered procedure codes are contingent on meeting clinical criteria in this CPB.
Not-covered/experimental codes: 0697T, 0698T, C8937.

Denial Risk

Routine Surveillance MRI Not Recommended

Routine use of breast MRI for surveillance/follow-up in asymptomatic patients after primary therapy (invasive cancer or DCIS) is not recommended by guideline panels and may be denied if requested without supporting indications. MRI with contrast is not indicated for routine follow-up/surveillance according to NCCN.

Use of Contrast, CAD, and Technical Considerations

Billing Rule

Use appropriate code for MRI with or without contrast

MRI of the breast may be performed with or without contrast as part of medically necessary indications; codes exist for without contrast, with contrast, and without‑and‑with contrast imaging.

Use appropriate CPT/HCPCS code based on whether contrast is used (e.g., 77046–77049; C8903–C8908).
Select code that matches the technical and contrast sequence performed when submitting claims/authorization.

Billing Rule

Document CAD use and interpretation sequence

When CAD is used, document how CAD results were incorporated into the MRI reading workflow, since the impact of CAD depends on whether it was used as an adjunct after initial read or to speed interpretation.

Specify whether CAD was applied after an initial radiologist read or used during primary interpretation.
Include a note on whether CAD findings influenced the decision to biopsy or additional imaging.

Study Frequency and Follow-up Intervals

inv-69: Implant rupture screening frequency — MRI no more frequently than every 2 years for screening silent intracapsular silicone implant rupture.

Maximum screening frequencyMRI for screening silent intra-capsular silicone implant rupture: no more frequently than every 2 years

First post-op MRIFirst MRI recommended at 3 years post-op (then every 2 years)

Appropriate modalityUse MRI for asymptomatic detection of intra-capsular silicone implant rupture; ultrasound sufficient for symptomatic rupture

inv-70: BI-RADS 3 follow-up frequency — follow-up MRI every 6 months for up to two years.

BI-RADS 3 follow-up intervalFollow-up MRI of BI-RADS 3 lesions every 6 months for up to two years is considered medically necessary when the lesion was originally detected by MRI

Reversion to routine imaging

Not Covered / Experimental Indications

Quantitative breast MRI techniques for tissue composition or density and related CPT/HCPCS codes (for example, 0697T, 0698T) and separate CAD HCPCS codes (for example, C8937) are listed in this bulletin as not covered/experimental for the indications described. In addition, many routine screening uses in average-risk individuals and other applications enumerated in the Not Covered section are not supported by Aetna.

Routine breast MRI for asymptomatic surveillance after primary therapy is not recommended and is generally considered not covered when used for routine follow-up without a specific clinical indication. Surveillance MRI requests should include documentation of prior conventional imaging and a clear clinical rationale; absence of guideline support (for example, ASCO and NCCN statements) increases the likelihood of denial for routine surveillance use.

Routine MRI for evaluation or screening of nipple discharge is considered not covered in most cases unless there is documented failure of conventional workup (mammography and ultrasound) and MR-guided biopsy capability is available. MRI used as a substitute for indicated surgical management (duct excision) is not supported.

Additional examples of noncovered uses include routine pre-operative MRI for typical newly diagnosed early-stage breast cancer and MRI screening of average-risk individuals or populations listed in the Experimental/Investigational section (such as screening for APC or GALNT12 mutation carriers or BRCA-positive men), where evidence is insufficient to support routine coverage.

Further noncovered uses include confirmatory MRI for implant rupture when ultrasound already documents rupture, quantitative MRI approaches for predicting recurrence, and other investigational indications listed in the Experimental/Investigational section of the policy.

Key Definitions and Terms

inv-51: High genetic risk for breast cancer — list of genes and carrier/relative definitions.

Included genes (examples)BRCA1, BRCA2, PALB2, TP53, PTEN, STK11 (Peutz-Jeghers), CDH1, NF1, ATM, CHEK2, BARD1, RAD51C, RAD51D

Carrier and relative definitionsIncludes individuals who carry a pathogenic germline variant and first-degree relatives of known carriers (eg, untested first-degree relative of BRCA1/2 carrier)

Management implicationCertain carriers begin MRI screening at specified ages (eg, BRCA1/2 beginning age 25; TP53 beginning age 20; many other genes beginning age 30–40 per gene-specific recommendations)

inv-52: BI-RADS 3 lesion definition and related follow-up recommendation.

DefinitionBI-RADS 3: a probably benign finding on MRI

Recommended follow-up

Prior Authorization Expectations

Note

Background and Evidence Context

Mammography is the only screening test proven to lower breast cancer morbidity and mortality and remains the foundation of population screening. Mammography sensitivity is reduced in dense breasts, and MRI can provide higher sensitivity as an adjunct in selected high-risk populations, but it has higher false-positive rates and has not demonstrated a mortality benefit when used broadly as a routine adjunctive screening test.

inv-04 (supporting): Additional evidence summaries

Additional evidence summaries referenced in background and clinical context

Surveillance MRI performance metrics: Prospective and cohort studies report varied cancer detection rates, sensitivities (eg, surveillance MRI sensitivity ~81.8% in one study), and CDRs stratified by timing after surgery; timing and background parenchymal enhancement affect performance and interpretation.

Policy History and Review Dates

1996-03-22policy_effective

Policy originally became effective.

2023-05-12last_reviewLatest

Policy last reviewed (documented review date).

2024-01-25next_scheduled_review

Next scheduled policy review date.

Policy Summary

PayerAetna

PolicyMagnetic Resonance Imaging (MRI) of the Breast

Policy CodePolicy 0105

Change TypeNo material change (routine review)

Effective DateMar 22, 1996

Next Review DateJan 25, 2024

Key ActionProvide documentation of prior conventional imaging and clinical rationale when requesting prior authorization for surveillance or screening breast MRI.

SourceLink

On This Page

ASCO guideline update (Khatcheressian et al, 2013).

MRI for response evaluation during neoadjuvant chemotherapy: Current evidence is weak and heterogeneous; MRI-derived parameters have not been consistently validated to guide clinical decisions about response to neoadjuvant chemotherapy.

Prevos et al (2012).

Use of CAD with breast MRI: Evidence is insufficient to conclude that CAD improves diagnostic performance for breast MRI; outcomes depend on how CAD is integrated into the reading workflow.

TEC assessment and related discussion.

Surveillance after breast-conserving therapy: Some studies report higher sensitivity and cancer detection rate for surveillance MRI compared with mammography and ultrasound in selected patients (younger women, dense breasts), but evidence is mixed and practice varies; background parenchymal enhancement and timing after adjuvant therapy affect MRI interpretation.

Screening in women with personal history of breast cancer: Evidence on MRI screening performance in women with a personal history is mixed; some data suggest favorable sensitivity/specificity and merit selective consideration, but routine recommendation for all such women is not established.

Problem-solving for equivocal DM/DBT findings: Breast MRI can be a useful adjunct for equivocal findings on diagnostic mammography/DBT after diagnostic ultrasound, with higher PPV and NPV in selected series.

Genetic mutation carriers (selected genes): NCCN recommends MRI screening (with contrast) starting at age 40 for carriers of certain variants (eg, CHEK2, ATM documentation) though mortality reduction has not been proven; use documented carrier status or calculated RLR to justify screening.age >=40

Use of risk models to guide MRI: Incorporate validated risk models and, where available, PV and polygenic risk information to stratify individuals (eg, CHEK2/ATM carriers) into RLR categories to guide screening and prevention strategies.

Selected pre-operative staging and contralateral screening at initial diagnosis

Pre-operative staging / contralateral screening: Consider MRI to evaluate extent of ipsilateral multifocal/multicentric disease and to screen the contralateral breast in selected patients at initial diagnosis (eg, when conventional imaging is indeterminate or in settings such as invasive lobular carcinoma or axillary adenocarcinoma with no identified primary); MRI frequently detects additional ipsilateral lesions (~16–20%) and contralateral cancers (~3–5%), but findings should be pathologically verified before altering surgical management.

Lehman et al (2007); Plana et al (2012).

inv-63: High-field MRI (3-T, 7-T) considerations

High-field MRI (3-T, 7-T) considerations

High-field MRI use: 3-Tesla and 7-Tesla scanners provide higher signal-to-noise ratio and improved spatial resolution compared with 1.5-T systems and may depict greater anatomic detail, but there are no large prospective trials demonstrating improved clinical outcomes; availability and local expertise should be considered when requesting high-field MRI.

inv-64: Response monitoring during neoadjuvant chemotherapy — investigational/limited

Response monitoring during neoadjuvant chemotherapy — investigational/limited

Neoadjuvant chemotherapy monitoring: MRI may be used investigationally to monitor response to neoadjuvant chemotherapy, but evidence is weak and heterogeneous; MRI-derived parameters (diameter, volume, kinetic measures, ADC) have not been consistently validated for distinguishing responders from non-responders and should not be the sole determinant of clinical management.

inv-65: Selected clinical indications summarized from literature

Selected clinical indications summarized from literature

Selected indications from literature: Includes evaluation of suspected fat necrosis post-surgery (MRI appearances variable and may mimic malignancy); selective use for unilateral bloody nipple discharge when conventional imaging is inconclusive (MRI not routinely recommended); intra-operative supine MRI to quantify tumor deformation and assess residual tumor (preliminary); surveillance MRI after breast-conserving therapy in selected patients (may show higher sensitivity than mammography/US in some studies); and supplemental screening in women with a personal history of breast cancer in selected contexts where MRI performance may be favorable; decisions should be individualized and documented.

inv-66: Selected diagnostic and screening indications with limited/institutional evidence

Selected diagnostic and screening indications with limited/institutional evidence

Problem-solving for equivocal DBT/DM findings: MRI may be indicated to further evaluate equivocal findings on diagnostic digital mammography/DBT when diagnostic ultrasound is inconclusive; studies report MRI correlates in a subset and higher PPV/NPV compared with DM/DBT.

Surveillance in women with personal history of breast cancer: Surveillance breast MRI may be considered in women with a personal history, particularly when performed >36 months after surgery where higher cancer detection rates have been reported; evidence is limited and institutional practices vary.>36 months post-surgery

Abbreviated MRI for screening: Abbreviated MRI protocols (abMRI) have reported short acquisition times (≈2.8–8.5 mins) and promising diagnostic performance (including in women with prior breast cancer), but evidence quality is very low and prospective multicenter validation is needed before routine adoption.

inv-67: Screening MRI for high-risk women

Screening MRI for high-risk women — genetic carriers or those with elevated residual lifetime risk due to atypia/LCIS/ADH

Genetic carrier screening: Offer contrast-enhanced MRI screening to documented carriers of specified pathogenic variants per NCCN guidance (start age varies by gene; some recommendations begin at age 25–30 for high-penetrance genes and at age 40 for certain moderate-risk genes); documentation of genetic status is required to justify screening.age thresholds per gene (eg, BRCA >=25, some genes >=30 or >=40)

Atypia / LCIS / ADH with elevated RLR: Consider annual MRI screening for individuals with ADH, LCIS, or ALH when remaining lifetime risk (RLR) calculated by validated models is >=20%; use risk models (BRCAPRO, Claus, Tyrer-Cuzick, Gail) and document rationale.RLR >=20%

Routine surveillance MRI not recommended — document specific clinical indication if ordering.

Prior Authorization

Prior Authorization: Document Prior Imaging and Clinical Rationale

Prior authorization may be required for surveillance or screening breast MRI. When prior authorization is requested, include documentation of prior conventional imaging (mammography ± ultrasound), clinical rationale for MRI, and any relevant risk assessment results (eg, calculated lifetime risk from BRCAPRO, Claus, Tyrer-Cuzick, or Gail).

Document prior mammography (generally within past year) and ultrasound when applicable.
Include radiologist's initial interpretation and reason MRI is needed beyond conventional imaging.

Prior Authorization

Prior Authorization Suggested for Abbreviated MRI

Abbreviated breast MRI (abMRI/FAST MRI) is an emerging approach with promising but limited evidence. Because larger studies with interval-cancer follow-up are needed, prior authorization is suggested when abMRI is used outside established guideline-supported indications.

abMRI may be considered investigational pending more robust evidence — suggest prior authorization.
Provide rationale and reference to clinical context when requesting abMRI.

Documentation Required

Implant MRI Technical and Documentation Considerations

For MRI ordered because of implant evaluation, follow FDA labeling and technical recommendations: first MRI at about 3 years post-implantation then every 2 years thereafter for silicone gel-filled implants; use MRI equipment ≥1.5 Tesla with a dedicated breast coil and a radiologist experienced in implant MRI.

Indication: detection of intra-capsular (silent) rupture of silicone gel-filled breast implants.
Schedule per FDA labeling: first MRI ~3 years post-op, then every 2 years; use ≥1.5T magnet and dedicated breast coil.

Documentation Required

Pathologic Verification Recommended for MRI-Detected Lesions

Pathologic verification is recommended when MRI-detected findings will change surgical management or prompt biopsy. Because MRI can overestimate disease extent and generate false-positives, tissue diagnosis should be obtained before definitive changes in therapy when feasible.

Obtain biopsy/pathology confirmation prior to converting to more extensive surgery or altering planned treatment.
When MR-guided biopsy is needed, ensure availability and document capability at the performing facility.

Documentation Required

Documentation Required for Nipple Discharge MRI

If MRI is being considered for evaluation of nipple discharge, document the results of conventional workup (mammography and ultrasound) and that MR-guided biopsy capability is available at the facility. MRI is not routinely recommended for nipple discharge and may be denied without documented rationale and prior workup.

Document mammogram and ultrasound results obtained for nipple discharge.
Confirm MR-guided biopsy availability if MRI will be used to evaluate discharge.

Documentation Required

Clinical Rationale and Timing Documentation for Surveillance MRI

When surveillance MRI is used, document the clinical rationale, timing relative to prior therapy or surgery, and any multidisciplinary decision-making. Retrospective studies show variable intervals and selection practices; include justification for timing (for example, >36 months post-surgery may have higher yield) and any institutional protocol.

Record interval since surgery or prior imaging and the clinical reason for surveillance MRI.
Note whether mammography and ultrasound were performed prior to MRI and influenced decision-making.

Documentation Required

Risk Assessment Documentation for High-Risk MRI Screening

When MRI screening is justified on genetic risk, include documentation of genetic carrier status or validated risk estimate demonstrating lifetime breast cancer risk ≥20% (eg, BRCAPRO, Claus, Tyrer-Cuzick, Gail). Cite the risk assessment tool used and include outputs when available.

Document genetic test results or family-history-based calculated lifetime risk ≥20%.
Specify which risk model was used and attach the risk score/report.

Prior Authorization

Prior Authorization and Plan Benefit Verification

Policy determinations depend on specific plan benefit provisions. Providers must verify member benefits and follow any plan-specific prior authorization procedures; Clinical Policy Bulletins are informational and do not guarantee coverage.

Prior authorization and benefit verification required per member's plan.
Clinical Policy Bulletins do not constitute a contract or guarantee of coverage.

Billing Rule

Document MR ductography technique and limitations

MR ductography uses heavy T2 weighting and does not require intravenous contrast; note limitations (may miss non‑dilated or low‑signal ducts) when documenting indication and technique.

If MR ductography is performed, document technique (heavy T2 weighting) and rationale for choosing it over standard contrast MRI.
Acknowledge limitations when submitting justification for MR ductography (may miss non‑dilated ducts).

Billing Rule

Document contrast use for abMRI and note gadolinium considerations

Abbreviated MRI protocols often use dynamic contrast‑enhanced sequences; document contrast use and consider gadolinium deposition concerns when using abMRI protocols.

abMRI commonly includes pre‑ and post‑contrast imaging; specify sequence used when requesting or billing.
Be aware that unenhanced DWI approaches are investigational and document rationale if avoiding contrast.

Billing Rule

Document genetic carrier status and guideline‑based screening age

For genetic high‑risk carriers, document carrier status and adherence to guideline‑recommended initiation age (NCCN recommends MRI with contrast starting at age 40 for certain variants) when requesting screening MRI.

Provide genetic test results or documented family history indicating carrier status.
Indicate patient age and reference NCCN recommendation when submitting authorization.

If repeat imaging is BI-RADS 1 or 2, subsequent imaging reverts to routine per individual risk profile

Initial evaluationMRI is not considered medically necessary for the initial evaluation of BI-RADS 3 lesions

inv-71: Abbreviated MRI frequency/status — Not specified / investigational.

Status of abbreviated MRIAbbreviated breast MRI (abMRI/FAST MRI) is investigational/limited evidence and not established as standard screening in this policy

Typical acquisition time targetAbbreviated protocols aim for total scanner time generally under 10–15 minutes (reported acquisitions 2.8–8.5 minutes)

Evidence noteSmall retrospective studies report promising diagnostic performance but larger prospective multicenter validation is needed before routine adoption

inv-72: MRI screening frequency for some indications — annual where specified.

Annual screening where specifiedWhen specified by guideline/indication (eg, ACS/NCCN guidance for many high-risk groups), MRI may be performed annually as part of screening adjunct to mammography

Contextual examplesAnnual MRI screening is recommended for many high-risk women (eg, BRCA carriers) per ACS guidance; use is adjunct to mammography

Not for average riskRoutine annual MRI screening is not supported for average- or intermediate-risk women (eg, solely for dense breasts) per ACOG and policy statements

Follow-up MRI every 6 months for up to two years when the lesion was originally detected by MRI; initial MRI not medically necessary for first evaluation of BI-RADS 3

Transition to routine careIf repeat imaging becomes BI-RADS 1 or 2, subsequent surveillance returns to routine per risk profile

inv-53: Computer-aided detection (CAD) — definition and role in MRI interpretation.

DefinitionComputer-aided detection (CAD) are software tools to assist radiologists in interpreting contrast-enhanced breast MRI

Role in interpretationCAD may be used to augment reading speed or as adjunct to initial read; impact on sensitivity/specificity depends on how CAD results are incorporated into workflow

Reimbursement noteAetna considers computer-aided detection integral to MRI of the breast and not separately reimbursed (and separate CAD HCPCS C8937 listed as not covered for indications in this bulletin)

inv-54: High-field MRI — definition (3-T, 7-T) and advantages/uncertainties.

DefinitionHigh-field MRI refers to scanners at 3-Tesla or 7-Tesla field strengths

AdvantagesHigher signal-to-noise ratio and improved spatial resolution compared with 1.5-T (eg, measured 5.7-fold SNR gain at 7-T vs 3-T in a small study)

UncertaintiesLack of large prospective trials demonstrating improved clinical outcomes; consider availability and expertise when requesting high-field MRI

inv-55: Fat necrosis — definition and imaging relevance.

DefinitionFat necrosis is a benign inflammatory process in breast tissue resulting from saponification of local fat

Imaging relevanceMRI has variable findings for fat necrosis and may lower post-operative MRI specificity; mammography and ultrasound are emphasized for diagnosis; many lesions may require biopsy

Clinical implicationPost-operative enhancing granulation tissue or fat necrosis can mimic malignancy and complicate MRI interpretation

inv-56: MR ductography — definition and limitations.

DefinitionMR ductography is an MRI technique using heavy T2 weighting to visualize fluid-containing ducts without intravenous contrast

LimitationsMR ductography may miss non-dilated ducts or ducts with low T2 signal (eg, hemorrhage or proteinaceous contents)

Clinical roleProvides 3D depiction of duct shape/location and can be helpful in selected women but is not routinely necessary for nipple discharge workup

inv-57: Abbreviated breast MRI (abMRI/FAST MRI) — definition and typical acquisition time target.

DefinitionAbbreviated breast MRI (abMRI/FAST MRI) is a shortened protocol intended to limit total scanner time (generally under 10–15 minutes) while preserving diagnostic sensitivity

Typical acquisition time targetReported total acquisition times in studies range ~2.8 to 8.5 minutes (with or without T2-weighted imaging)

Evidence statusSmall studies show promising performance but approach remains investigational pending larger prospective validation

inv-58: Problem-solving breast MRI — definition and typical use after diagnostic mammography/tomosynthesis.

DefinitionProblem-solving breast MRI is performed to further evaluate equivocal findings on diagnostic mammography or digital breast tomosynthesis when ultrasound is inconclusive

Typical useUsed after diagnostic mammography/DBT and ultrasound to clarify inconclusive assessments and guide biopsy decisions; studies report higher PPV/NPV for MRI in selected equivocal cases

Prior imagingPerform diagnostic ultrasound and mammography/DBT before considering problem-solving MRI

inv-59: Pathogenic variant (PV) — definition and examples (BRCA1/2, PALB2, etc.).

DefinitionPathogenic variant (PV) is a germline genetic alteration in a cancer-predisposition gene associated with increased breast cancer risk

ExamplesExamples include BRCA1, BRCA2, PALB2, CHEK2, ATM, BARD1, RAD51C, RAD51D, TP53, PTEN, CDH1

ImplicationIdentification of a PV may alter screening recommendations (eg, earlier and adjunct MRI screening per gene-specific guidance)

inv-60: Residual lifetime risk (RLR) — definition and use in categorizing patients for screening decisions.

DefinitionResidual lifetime risk (RLR) is the estimated probability of developing breast cancer over the remaining lifetime used to stratify screening decisions

Decision thresholdRLR >= 20% (or 20–25%) is used to categorize patients for consideration of adjunct MRI screening per guideline and policy statements

Risk modelsRLR estimates can be derived from models such as BRCAPRO, Claus, Gail, or Tyrer-Cuzick and are used to guide MRI consideration in atypia/LCIS/ADH