CPT inclusion does not imply PA

The inclusion of a CPT code in this guideline does not by itself mean that the code requires prior authorization; prior authorization requirements are managed separately and condition-specific sections determine any PA needs.

CPT listing ≠ management/PA requirement

Inclusion of CPT codes in the guideline does not indicate the code is managed or requires prior authorization; verify PA requirements through applicable management policies rather than by CPT listing alone.

PA may be required for 3D rendering (76376/76377)

Requests for 3D rendering (CPT® 76376, 76377) may require prior authorization even when the base imaging study does not; document physician concurrent supervision when applicable.

• Concurrent physician participation/monitoring of the reconstruction process must be documented.
• Do not use 76376/76377 with MRI breast, 3D mammography, or ABUS per guideline prohibitions.

Justify unlisted CT (76497) / MR (76498) usage

When reporting unlisted CT (CPT 76497) or unlisted MR (CPT 76498), provide clinical justification and prefer a Category III code if available; these unlisted codes are used when no anatomic site-specific code exists.

• Document why a site-specific CPT is not appropriate (e.g., neurosurgical navigation/planning, custom joint arthroplasty planning, thinner cuts or alternative positioning).
• Provide condition- or procedure-specific justification in the submission.

PA and step requirement for PET/MRI (report as 78813+76498)

Prior authorization for PET/MRI is required when substituting for PET/CT: the patient must meet PET/CT guideline criteria AND PET/CT must be unavailable at the treating institution, with the provider specifically requesting PET/MRI; approved reporting uses CPT 78813 + CPT 76498.

• If PET/MRI is requested as an alternative to PET/CT, document that PET/CT criteria are met and PET/CT is unavailable.
• When approved, report PET/MRI with CPT 78813 + CPT 76498.

Use bilateral without/with contrast codes when MRI breast indicated

When MRI of the breast is clinically indicated per the guideline, use bilateral without-and-with contrast codes (e.g., CPT 77049 or HCPCS C8908) as the preferred study and ensure coding aligns with the documented indication.

• Unilateral breast MRI is not clinically supported except as specified.
• CAD is included with CPT 77049/77048; do not bill 3D rendering with breast MRI.

PA required for bilateral contrast breast MRI (77049/C8908)

Prior authorization is required when requesting MRI Breast bilateral without and with contrast (CPT 77049 or HCPCS C8908) to confirm medical necessity for indications such as high‑risk screening, post‑biopsy follow‑up, discordant biopsy, or radiologist/treating provider recommendation.

• Provide documentation of the specific indication (e.g., high‑risk criteria or radiologist recommendation).
• Annual screening for qualifying high‑risk individuals uses CPT 77049/C8908 when criteria met.

Provide prior imaging and BI‑RADS when requesting MRI

Document prior imaging (diagnostic mammogram and/or breast ultrasound) and their BI‑RADS interpretations when requesting subsequent breast MRI to establish medical necessity for implant evaluation, pathologic nipple discharge, or other scenarios where prior imaging is required.

• For implant evaluation: if ultrasound/mammogram indeterminate, document results before MRI (CPT 77047 may be appropriate).
• For nipple discharge or other indications, include BI‑RADS category and radiology findings in the request.

PA required for MRI (77049/C8908) and MBI (78800) requests

Prior authorization is required when requesting MRI Breast bilateral without and with contrast (CPT 77049 / HCPCS C8908) or Molecular Breast Imaging (CPT 78800) per the guideline criteria (e.g., to complete screening, radiologist recommendation, high‑risk screening, or when MRI contraindicates MBI).

• Document why MRI or MBI is indicated (radiologist recommendation, provider request to complete screening, or high‑risk criteria).
• If MRI is contraindicated and MBI is requested, document contraindication to MRI.

PA required for breast MRI and 3D rendering requests

Prior authorization is required for MRI breast bilateral without and with contrast (CPT 77049/HCPCS C8908) and for 3D rendering (CPT 76376/76377) requests; for 3D rendering, document clinical necessity given prohibitions (e.g., not with MRI breast or 3D mammography).

• If requesting 3D rendering, explain clinical scenario and document active physician supervision/participation.
• Do not bill 3D rendering with breast MRI or 3D mammography per guideline; include justification if requested regardless.

PA and documentation for preoperative MRI in malignant phyllodes

Preoperative MRI Breast bilateral without and with contrast (CPT 77049 or HCPCS C8908) is medically necessary and requires documentation of prior tissue diagnosis when requested for biopsy‑proven malignant phyllodes tumor.

• Include the prior tissue diagnosis demonstrating malignant phyllodes in the authorization request.

Document radiologist/provider recommendation and prior imaging for MRI after suspicious initial imaging

MRI Breast bilateral without and with contrast (CPT 77049/HCPCS C8908) is medically necessary for clinically suspicious cases after initial imaging (BI‑RADS 1–3) when requested by the treating provider or recommended by the radiologist; include prior imaging and findings in the request.

• If initial mammogram/US is BI‑RADS 4 or 5, MRI is not medically necessary—document biopsy plans instead.
• Document radiologist or treating provider recommendation and the imaging that prompted the MRI request.

PA process may use InterQual or plan policies

UnitedHealthcare may use InterQual or other approved internal guidelines to administer prior authorization; if InterQual lacks applicable criteria, UnitedHealthcare's Medical Policies and Coverage Determination Guidelines (approved by the Ohio Department for Medicaid Services) may be used.

Clinician judgment may override guidelines

Clinical judgment may override guideline recommendations; ensure that any divergence from guideline-based stepwise imaging is documented with the clinical rationale.

Confirm pre‑imaging clinical evaluation is completed

Ensure a clinical evaluation by the treating physician or consultant has occurred prior to ordering advanced imaging; exceptions exist for guideline‑supported scheduled follow‑up imaging.

• Document pertinent history, physical exam, labs, and prior imaging in the request.
• Telehealth or other meaningful technological contact since symptom onset may suffice if appropriate.

Not applicable

(Not applicable.)

Not applicable

(Not applicable.)

Require PET/CT criteria met before approving PET/MRI

PET/MRI requests must meet PET/CT guideline criteria first (or document PET/CT unavailability) before PET/MRI will be approved as an alternative to PET/CT.

• Document that PET/CT criteria are met and that PET/CT is not available at the treating institution if PET/MRI is requested instead.

Use ultrasound as alternative when MRI cannot be performed

When MRI cannot be performed (e.g., incompatible device, claustrophobia, inability to receive contrast), breast ultrasound may be used as a supplemental screening alternative for high‑risk females with dense breasts; document the reason MRI is not possible.

• Specify the MRI contraindication (e.g., non‑MRI compatible device, inability to receive contrast, or intolerable claustrophobia).
• If used for supplemental screening, document high‑risk status and dense breast findings.

Not applicable

(Placeholder — no action specified.)

Stepwise imaging: ultrasound ± diagnostic mammogram before MRI

Follow a stepwise imaging approach before MRI: perform breast ultrasound (CPT 76641/76642) ± diagnostic mammogram first; proceed to MRI if initial imaging is indeterminate or other MRI criteria are met.

• For palpable masses and skin changes, document diagnostic mammogram and/or ultrasound results and BI‑RADS category prior to MRI.
• If initial imaging is BI‑RADS 4 or 5, biopsy is recommended rather than MRI.

Age‑based initial imaging for focal breast pain (<30 = US; ≥30 = mammogram+US)

For focal breast pain: if age <30 years, order ultrasound first; if age ≥30 years, obtain diagnostic mammogram plus targeted ultrasound as initial imaging before considering MRI.

Perform diagnostic mammogram/US before MRI for palpable masses

Perform diagnostic mammogram and/or breast ultrasound (age‑dependent) as the initial imaging before advanced imaging (MRI) for palpable masses; if initial studies are BI‑RADS 4 or 5, proceed to biopsy rather than MRI.

Include provider or radiologist recommendation to justify MRI after screening mammogram/US

Document the radiologist or treating provider request or recommendation when requesting MRI following a screening mammogram or ultrasound; this can justify MRI to complete screening or address a finding.

• Include the radiology report recommendation or explicit provider request in the documentation.
• Attach prior mammogram/US reports and BI‑RADS assessment.

Provide complete clinical documentation for case‑by‑case determinations

For requests that require case‑by‑case determinations, include personal and family history, physical exam findings, and symptom chronology as these inform individualized coverage decisions.

• Provide detailed history, exam findings, laboratory data (if relevant), and prior imaging.
• Explain how the requested imaging will affect management.

Document physician concurrent supervision for 3D rendering

Document active physician participation/monitoring of the 3D reconstruction process when billing CPT 76376/76377, including design of the anatomic region, selection of tissues/structures to display, and monitoring/adjustment of the 3D work product.

• Failure to document concurrent supervision/participation may risk denial.
• Describe the physician's role in the reconstruction and the clinical decision supported by the 3D rendering.

Provide justification when using unlisted/HCPCS codes

When reporting HCPCS or unlisted procedure codes, provide an explanation for why a site‑specific CPT or Category III code is not available and reference the condition‑specific guideline when applicable.

• Include procedure details and clinical justification in the submission.
• Cite the applicable guideline section that supports the unlisted code use.

Document indication and use CPT 76498 for WBMRI / 78813+76498 for PET/MRI

For Whole‑body MRI or PET/MRI reporting, document the indication and adherence to condition‑specific guideline criteria; when reporting WBMRI use CPT 76498 and when reporting PET/MRI use CPT 78813 + CPT 76498 per guideline instructions.

• Document condition‑specific criteria or an explanation of PET/CT unavailability when requesting PET/MRI.
• Use CPT 76498 for WBMRI reporting as other whole‑body reporting methods are inappropriate.

Document discordant biopsy findings to support MRI requests

Document histopathologic discordance between core‑needle biopsy findings and imaging findings when requesting MRI for further evaluation after a discordant biopsy; include pathology and imaging reports.

• Include biopsy pathology report and the imaging that is discordant (BI‑RADS 4 or 5 findings that are not explained by biopsy).
• State why MRI is needed for further evaluation and how results would change management.

Include radiology/provider recommendation and prior imaging when requesting MRI

When requesting MRI, include the radiologist or treating provider recommendation, the relevant radiology report findings (e.g., mammogram/US findings prompting MRI), and timing relative to any biopsy; this information is required to establish medical necessity.

• Attach prior imaging reports and BI‑RADS assessments.
• Note the timing of MRI relative to biopsy (e.g., at least 6 months after biopsy for certain follow‑up indications).

Document prior equivocal implant imaging before requesting MRI (77047)

When initial imaging is equivocal for implant rupture, document the initial ultrasound or diagnostic mammogram and their indeterminate/BI‑RADS results before requesting MRI; MRI Breast bilateral without contrast (CPT 77047) is medically necessary if prior studies are indeterminate.

• For <30 years old: ultrasound is initial imaging; for ≥30, ultrasound or diagnostic mammogram is initial imaging.
• If prior imaging is indeterminate, include those reports to support MRI 77047 request.

Include provider/radiologist request to justify MRI after screening

Provider request or radiologist recommendation can justify MRI following a screening mammogram/US to complete screening or address a finding; include that recommendation in the authorization documentation.

Document diagnostic mammogram/US results and BI‑RADS for palpable masses and skin changes

For palpable masses and skin changes, document diagnostic mammogram and/or breast ultrasound results and BI‑RADS category; if BI‑RADS 4 or 5, document biopsy recommendation or plan rather than requesting MRI.

• Attach diagnostic mammogram and ultrasound reports with BI‑RADS assessments.
• If biopsy is planned or performed, include biopsy scheduling or results in the submission.

Provide age, presenting signs, initial imaging and tissue diagnosis for preoperative MRI

Document patient age, presence of nipple discharge or skin changes, initial imaging modality and BI‑RADS assessment, and tissue diagnosis when requesting preoperative MRI for malignant phyllodes tumor or other condition‑specific indications.

• Include tissue diagnosis for malignant phyllodes when requesting preoperative MRI.
• Provide the initial imaging and BI‑RADS to support MRI necessity.

Verify governing federal/state/contractual benefit requirements

Providers should check federal, state (Ohio Administrative Code) or contractual benefit plan coverage before using this guideline as coverage terms may differ; in the event of conflict, those requirements govern.

Denial risk: investigational, experimental, research‑only imaging

Requests for imaging that are investigational, experimental, unproven, requested for data collection only, inconsistent with established clinical standards, or lacking sufficient supporting evidence may be denied as not medically necessary.

• If the procedure is investigational or for research/data collection without clinical management intent, the request may be denied.
• Provide peer‑reviewed evidence or guideline support when requesting imaging with limited evidence.

Denial risk for overutilization or unnecessary/duplicate imaging

Requests may be denied or considered unnecessary if duplicate or questionably medically necessary imaging is ordered, if pre‑operative imaging is for a surgery that is not medically necessary, or if imaging is ordered without review of prior relevant studies and clinical history.

• Review prior imaging before ordering additional studies and document why repeat imaging is clinically necessary.
• Ensure requested imaging will affect patient management to avoid denial for overutilization.

Denial risk if 3D rendering supervision not documented

Failure to document active physician concurrent supervision or participation in the 3D reconstruction process when billing CPT 76376/76377 may result in denial; documentation should describe the physician's role in design, selection, and monitoring of the 3D product.

• Describe specific supervisory actions taken during the 3D reconstruction.
• Cite the clinical reason why 3D rendering was necessary.

Denial risk for whole‑body screening CT/MRI

Whole‑body CT screening for asymptomatic individuals and most whole‑body MRI requests are not covered or are generally not medically necessary and may be denied; WBMRI is allowed only for select cancer predisposition syndromes or specified conditions.

• If WBMRI is requested, document the specific cancer predisposition syndrome or condition that meets guideline exceptions.
• Use CPT 76498 for WBMRI reporting and include condition‑specific justification.

Denial risk for WBMRI outside listed exceptions

WBMRI is generally not medically necessary except for select cancer predisposition syndromes, multiple myeloma staging/restaging, or certain autoimmune conditions; requests outside these exceptions risk denial.

• Document condition‑specific criteria and reference the applicable oncology/pediatric guideline section when requesting WBMRI.

Denial risk for PET/MRI when criteria not met

PET/MRI is generally not medically necessary for most oncologic and neurologic conditions; requests that do not meet condition‑specific criteria or the PET/CT substitution criteria (meet PET/CT criteria and PET/CT unavailable) risk denial.

• Document why PET/CT cannot be performed at the treating institution if PET/MRI is requested instead.
• Attach condition‑specific guideline support when applicable.

Denial risk for routine ultrasound screening

Routine breast ultrasound as a stand‑alone screening test or performed with screening mammography is not medically necessary and may be denied.

• For supplemental screening in high‑risk dense breasts when MRI cannot be performed, document high‑risk status and MRI contraindication.
• Routine use for average‑risk screening is not supported.

Denial risk if contrast‑enhanced MRI performed without gadolinium when indicated

Gadolinium contrast is required for evaluation of breast parenchyma; absence of contrast when contrast‑enhanced MRI is indicated may render the MRI non‑supportable and risk denial.

• If contrast cannot be given (e.g., pregnancy, severe renal impairment), document the contraindication and consider alternative imaging per guideline.
• For implant integrity evaluation in asymptomatic individuals, non‑contrast MRI (CPT 77047) is appropriate and contrast is not necessary.

Denial risk: routine MRI after bilateral mastectomy

Routine MRI Breast following bilateral mastectomy is NOT medically necessary even if high‑risk criteria would otherwise be met and therefore may be denied.

Denial trigger: MRI for capsular contracture

Breast MRI for evaluation of capsular contracture is explicitly stated as NOT medically necessary and would be a denial trigger; do not request MRI for capsular contracture evaluation.

Denial risk for routine asymptomatic implant surveillance

Routine imaging for asymptomatic saline implants is not medically necessary and may be denied; surveillance imaging for silicone implants is managed by timing rules (see implant surveillance guidance).

• For silicone implants: routine imaging is not necessary until ≥5 years post‑placement; thereafter ultrasound is recommended and repeat every 2–3 years if negative.
• For saline implants: routine imaging for asymptomatic individuals is not indicated.

MRI supported only when MRI screening criteria met; MBI as MRI alternative when contraindicated

MRI is supported only when criteria for breast cancer screening with MRI are met; MBI may be used when MRI is indicated but contraindicated — document that MRI criteria are met and state the MRI contraindication if requesting MBI.

• If requesting MBI (CPT 78800), document why MRI is contraindicated and provide evidence that MRI screening criteria are otherwise satisfied.

Denial risk: advanced imaging for breast pain and male breast MRI

Advanced imaging for breast pain and MRI for male breast disease are generally not medically necessary and may be denied unless specific guideline indications are met and documented.

• For focal breast pain, follow age‑based initial imaging rules (US <30; mammogram+US ≥30).
• MRI for male breast disease is not medically necessary given limited supporting evidence.

High denial likelihood for male breast MRI

Requests for male breast MRI are likely to be denied because MRI of the male breast is stated to be not medically necessary in the guideline.

• Use diagnostic mammogram and/or breast ultrasound (CPT 76641/76642) for symptomatic male breast evaluation.

Denial risk for 3D rendering billed with 3D mammography/ABUS/MRI

Billing 3D rendering (CPT 76376/76377) in conjunction with 3D mammography, automated breast ultrasound (ABUS), or breast MRI is prohibited and may be denied; do not submit concurrent billing for those combinations.

• If 3D rendering is submitted, ensure it is not billed with prohibited modalities and provide justification if exceptions are claimed.

Denial risk: MRI not supported for BI‑RADS 4 or 5 initial imaging

Breast MRI is not medically necessary when the initial diagnostic mammogram or breast ultrasound is BI‑RADS category 4 or 5; document that biopsy is planned or performed rather than requesting MRI in this setting.

• If BI‑RADS 4 or 5, provide biopsy plan or pathology rather than MRI request.
• Requests for MRI in lieu of biopsy in BI‑RADS 4–5 cases risk denial.

Check governing benefit requirements; they govern in conflicts

Coverage determinations must reference federal, state (Ohio Administrative Code) or contractual benefit requirements; if those requirements conflict with this guideline, they govern—verify and document applicable benefit terms.