CIGNA Medical Coverage Policies - Radiology: Breast Imaging Guidelines
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Covers Cigna medical coverage policy guidance for breast imaging procedures and related indications used by eviCore to determine medical necessity for health plans administered by Cigna.
No material clinical or coverage changes in this revision.
Coverage Criteria — Breast Imaging
MRI Breast (general)
MRI Breast coverage and coding guidance
When MRI Breast is medically necessary, CPT 77049 or HCPCS C8908 (bilateral without and with contrast) is supported unless an indication specifies noncontrast imaging (e.g., implant rupture evaluation).
Breast reconstruction imaging
Pre-operative imaging for breast reconstruction (free-tissue transfer flaps)
Routine use of CTA chest to evaluate recipient vessels is NOT medically necessary except when prior cardiac/vascular surgery or known vascular anomalies are present.
MRI after screening mammogram/US
MRI Breast Bilateral without and with contrast (CPT 77049 or HCPCS C8908) is medically necessary for EITHER of the following when following a screening mammogram and/or ultrasound in asymptomatic individuals:
When medical necessity is met with one of these indications, bilateral contrast-enhanced MRI (CPT 77049 or HCPCS C8908) is the supported study; alternate unilateral/bilateral MRI codes are acceptable per guideline coding rules.
Post-biopsy or attempted biopsy imaging
Post-biopsy MRI indications related to lesions initially seen on MRI:
Also medically necessary 6 months after attempted MRI-guided biopsy when the targeted lesion was not visualized at procedure and radiologist recommends follow-up.
Surveillance and high-risk screening
Follow-up protocol and high-risk screening:
If repeat imaging becomes BI-RADS 1 or 2, revert to routine screening per individual's risk profile.
Age- and gene-specific start ages are provided in the risk factors section.
Screening breast MRI — high-risk indications
Covered when ANY of the following risk-based conditions are met (per document statements and referenced guideline age thresholds):
Accepted models enumerated in document.
See evidence discussion for mutation-specific age recommendations.
Document specifies start at 25 or 8 years after radiation, whichever comes later.
Document cites differing guideline positions.
Post-biopsy or canceled MRI-guided biopsy
Covered when ALL of the following are met:
Cited study recommends 6-month follow-up MRI due to a small missed malignancy risk.
Breast implant evaluation — coverage criteria
Coverage varies by implant type and clinical scenario:
If exam is equivocal for rupture: <30 years ultrasound; >=30 years ultrasound or diagnostic mammogram; MRI without contrast if prior imaging indeterminate.
Document provides implant-type and time-since-placement rules and sequencing.
For saline implants, initial imaging depends on age as above.
Postmastectomy imaging stance
Not routinely covered based on available evidence:
ACR Appropriateness Criteria referenced.
Asymptomatic implant screening
Not covered/limited:
Cigna explicitly does NOT cover surveillance MRI for implants placed purely for cosmetic reasons.
Physiologic nipple discharge
Covered when the following age-based conditions are met for physiologic nipple discharge:
Refer to pituitary imaging guidance if concern for prolactinoma.
Pathologic nipple discharge
Covered when ALL of the following age- and imaging-result-based conditions are met for pathologic nipple discharge:
Biopsy recommended instead of MRI.
Breast pain (mastodynia)
Covered when criteria based on focality and age are met:
Advanced imaging (e.g., MRI) is NOT medically necessary for breast pain or breast abscesses.
Alternative imaging (MRI, MBI)
Covered alternative imaging scenarios:
See high-risk MRI screening criteria for eligibility.
High-risk MRI screening
Annual MRI Breast screening is medically necessary for individuals meeting specified high-risk criteria and age thresholds:
Some genes (MSH2, MLH1, MSH6, PMS2, EPCAM, NBN) lack sufficient evidence for MRI screening.
Annual MRI NOT medically necessary after bilateral mastectomy even if high-risk criteria otherwise met.
Document cites differing guideline positions.
High-risk supplemental screening
Supplemental MRI/alternate imaging coverage for high-risk individuals
Certain genes/variants of uncertain or intermediate penetrance are NOT sufficient evidence for MRI surveillance.
Male screening and diagnostic criteria
Male breast imaging
MRI of the male breast is NOT medically necessary.
Pregnant/lactating patient imaging
Pregnancy and lactation evaluation
MRI with gadolinium should not be used in pregnant patients; MRI may be supported in lactating women when criteria are met.
Transgender screening criteria
Transgender supplemental screening
Acceptable lifetime-risk models are Gail, Tyrer-Cuzick, BCSC, BOADICEA/CanRisk, or BRCAPRO.
Transmasculine high-risk annual supplemental screening
Supplemental annual breast ultrasound and/or MRI screening is medically necessary when ALL of the following are met:
Document requires objective lifetime-risk calculation using accepted models and documentation of surgical history and transmasculine status.
Not medically necessary: supplemental screening (transgender populations)
Annual supplemental ultrasound and/or MRI screening is NOT medically necessary for ANY of the following:
Supplemental MRI/ultrasound screening reserved only for the specified high-risk transmasculine group.
Breast mass imaging criteria
For evaluation of a breast mass:
MRI is NOT medically necessary to determine biopsy recommendations for lesions that can be readily biopsied on physical exam.
MRI should not be used to bypass biopsy.
Proceed to biopsy rather than MRI.
Skin changes imaging criteria
For skin changes of the breast:
If initial imaging is BI-RADS 4-5, MRI is not indicated and biopsy is recommended.
Advanced imaging is NOT medically necessary for breast abscesses.
Nipple inversion/retraction imaging criteria
When no palpable mass is present and nipple inversion/retraction is acquired/new onset:
Follow nipple discharge or skin change pathways if those symptoms are present.
If BI-RADS 4-5, biopsy recommended and MRI not medically necessary.
Pre-operative MRI for malignant phyllodes
Covered when ALL of the following are met
MRI is supported for pre-operative staging of malignant phyllodes; MRI is NOT useful to distinguish phyllodes from fibroadenoma.
No explicit coverage exclusions are listed in the table of contents excerpt for this guideline. The TOC entries enumerate sections (e.g., Nipple Discharge/Galactorrhea, Breast Pain, Alternative Breast Imaging Approaches, Breast Imaging in Males, Breast Evaluation in Pregnant or Lactating Females) but do not by themselves state specific exclusions.
Per the MRI Breast guidance, gadolinium contrast is required when evaluating breast parenchyma, but the guideline explicitly states that the use of gadolinium contrast is NOT medically necessary for the evaluation of implant integrity in asymptomatic, average-risk individuals; when implant integrity imaging is indicated, a non-contrast MRI (CPT 77047) is specified for rupture evaluation.
Routine CTA of the chest to evaluate recipient vessels for flap reconstruction is described as NOT medically necessary, with limited exceptions for prior chest surgery or known vascular anomalies. Likewise, routine bilateral breast MRI following bilateral mastectomy is stated as NOT medically necessary even if other high-risk screening criteria would otherwise apply.
Cigna does NOT cover surveillance MRI for breast implants that were placed solely for cosmetic purposes; surveillance imaging for implants is otherwise guided by implant type and clinical scenario.
Covered Indications — Topic Map
The document contains multiple breast imaging indication sections as listed in the table of contents.
The document contains multiple breast imaging indication sections as listed in the table of contents.
See table of contents for full section listing.
Coding — Procedure and Status Tables
| 77049 | MRI Breast Bilateral, including CAD, without and with contrast |
| C8908 | HCPCS MRI Breast Bilateral, without and with contrast |
| 77047 | MRI Breast Bilateral, without contrast |
| C8937 | CAD including computer algorithm analysis of MRI Breast data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation |
| 76376 | 3D rendering; interpretation and reporting (note: not to be used with MRI Breast when CAD automatically performs 3D imaging) |
| 76377 | 3D rendering; image processing (note: not to be used with MRI Breast when CAD automatically performs 3D imaging) |
| 19085 | MRI-guided breast biopsy (includes imaging component and needle placement) |
| 77021 | MR guidance for needle placement (not appropriate to bill in addition to CPT 19085) |
| 19086 | Addition for multiple lesions in breast biopsy (additional lesion) |
| 77049 | MRI Breast Bilateral without and with contrast |
| C8908 | MRI Breast Bilateral without and with contrast (HCPCS) |
| 77046 | MRI Breast Unilateral without contrast |
| 77047 | MRI Breast Bilateral without contrast |
| 77048 | MRI Breast Unilateral without and with contrast |
| C8903 | MRI Breast Unilateral with contrast (HCPCS) |
| C8905 | MRI Breast Unilateral without and with contrast (HCPCS) |
| C8906 | MRI Breast Bilateral with contrast (HCPCS) |
| 76641 | Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete |
| 76642 | Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited or follow-up |
| 77047 | Magnetic resonance (e.g., breast), without contrast material, bilateral |
| 76641 | Breast ultrasound, unilateral, real-time with image documentation; complete |
| 76642 | Breast ultrasound, unilateral, real-time with image documentation; limited |
| 77049 | Magnetic resonance (e.g., breast), bilateral without and with contrast |
| C8908 | HCPCS alternative for breast MRI (bilateral without and with contrast) |
| 78800 | Molecular breast imaging (MBI) |
| 0633T | CT Breast (proprietary CPT series listed as examples) |
| 0634T | CT Breast |
| 0635T | CT Breast |
| 0636T | CT Breast |
| 0637T | CT Breast |
| CPT 78811 | PET scan of the breast (referenced as how providers request PEM) |
| 77049 | Magnetic resonance (e.g., breast), bilateral, without and with contrast material |
| C8908 | Breast MRI bilateral without and with contrast (HCPCS equivalent) |
Provider Actions — Authorization, Documentation, Billing
eviCore review required for specified high‑tech imaging
Some high‑tech imaging procedures for Cigna members are reviewed by eviCore; providers must consult the Cigna CPT code list to determine which procedures require eviCore review.
Prior authorization (TOC — no details)
This table of contents excerpt does not describe specific prior authorization procedures or submission requirements.
Prior authorization (not specified in excerpt)
The provided excerpt contains section headings and page references but does not specify operational prior authorization rules or steps.
Follow eviCore/Cigna prior authorization process
These guidelines apply to services and supplies managed by eviCore for Cigna; providers must follow eviCore/Cigna prior authorization processes as outlined by the Cigna CPT list when applicable.
Prior authorization required for implant imaging pathways
Prior authorization is required for imaging requested for implant evaluation pathways; ultrasound (CPT 76641/76642), diagnostic mammography, or MRI Breast Bilateral without contrast (CPT 77047) must be authorized when indicated by the guideline.
Prior authorization for MRI and MBI per medical‑necessity criteria
When MRI Breast Bilateral without and with contrast (CPT 77049 or HCPCS C8908) is being requested per medical‑necessity criteria (e.g., to complete screening, radiologist recommendation, or to address a mammogram/US finding), prior authorization applies; Molecular Breast Imaging (CPT 78800) is supported when MRI is contraindicated and also requires authorization.
Prior authorization for investigational CT breast and alternative modalities
CT breast procedures (CPT 0633T–0638T) and other alternative breast imaging modalities are considered investigational; expect that prior authorization will be required and that requests may be denied without compelling supporting evidence.
- Investigational CT Breast CPT codes: 0633T–0638T
- Other investigational modalities include scintimammography, BSGI, PEM, thermography, impedance mammography, cone beam CT
Prior authorization for transmasculine supplemental screening
Requests for supplemental ultrasound (CPT 76641/76642) and/or MRI breast (CPT 77049 or HCPCS C8908) in transmasculine individuals who meet ALL specified risk criteria require documentation and prior authorization per the guideline.
Prior authorization required for advanced imaging and 3D rendering
Advanced imaging codes (e.g., bilateral breast MRI CPT 77049/HCPCS C8908; ultrasound CPT 76641/76642; 3D rendering CPT 76376/76377) require prior authorization and must meet the clinical criteria described in the guideline.
Prior authorization for pre‑operative bilateral breast MRI (malignant phyllodes)
Prior authorization is expected when bilateral contrast‑enhanced breast MRI (CPT 77049 or HCPCS C8908) is requested pre‑operatively to establish extent of disease for a biopsy‑proven malignant phyllodes tumor; the request must cite prior tissue diagnosis.
Prior authorization (references section — none stated)
This references section does not state any additional prior authorization requirements.
MRI BI‑RADS 3 surveillance schedule
For MRI‑detected BI‑RADS 3 lesions, perform repeat MRI at 6 months; if still BI‑RADS 3, continue MRI at 12, 18, and 24 months from the initial imaging, and consider the lesion benign after 2 years of stability.
- Surveillance schedule: 6, 12, 18, and 24 months
- Assess as benign (BI‑RADS 2) after 2 years of stability
Imaging sequence for implant evaluation — start with ultrasound/mammogram
For implant evaluation, follow a sequential imaging approach: ultrasound (preferred in younger individuals) and/or diagnostic mammogram first; if prior imaging is indeterminate, MRI Breast Bilateral without contrast (CPT 77047) is medically necessary.
Pregnancy imaging — ultrasound first, avoid gadolinium
In pregnant patients, breast ultrasound (CPT 76641/76642) is first‑line; if ultrasound is negative or suspicious for a palpable mass or persistent bloody nipple discharge, follow with diagnostic mammogram with abdominal shielding rather than proceeding directly to gadolinium‑enhanced MRI, since IV gadolinium is contraindicated in pregnancy.
Specify a medically necessary indication when requesting breast MRI
Requests for MRI Breast must specify a medically necessary indication (for example: to complete screening when requested by the treating provider, recommended by the radiologist, or to address a finding on mammogram/US); lack of such indication may lead to denial.
- Supported reasons include: provider request to complete screening, radiologist recommendation, or to address a mammogram finding
Implant surveillance for cosmetic implants is not covered
Surveillance MRI for breast implants placed solely for cosmetic reasons is not covered by Cigna and may be denied.
Investigational alternative imaging modalities — denial risk
Requests for alternative breast imaging techniques listed as investigational (e.g., scintimammography, BSGI, PEM, thermography, impedance mammography, CT Breast, cone beam CT) are considered investigational and may be denied for screening or diagnostic use.
- Investigational modalities include CT Breast (CPT 0633T–0638T), PEM, BSGI, scintimammography, thermography, impedance mammography, cone beam CT
Gadolinium contrast contraindicated in pregnancy — potential denial
Requests for breast MRI with IV gadolinium in pregnant patients may be denied because IV gadolinium is contraindicated in pregnancy.
Do not use MRI to avoid biopsy for readily biopsied palpable masses
Do not request breast MRI to determine biopsy recommendations for palpable masses that can be readily biopsied; proceed to biopsy rather than MRI, as MRI for this purpose is not supported and may be denied.
MRI not supported when prior imaging is BI‑RADS 4–5 — biopsy indicated
Requests for Breast MRI when prior diagnostic mammogram or ultrasound demonstrates BI‑RADS category 4 or 5 will be denied because MRI is not medically necessary for lesions that require biopsy.
Pre‑op bilateral MRI for malignant phyllodes requires prior tissue diagnosis
Bilateral contrast‑enhanced breast MRI for pre‑operative staging of malignant phyllodes is supported only when a prior tissue diagnosis of malignant phyllodes has been established by percutaneous core biopsy or excisional biopsy; requests without prior tissue diagnosis do not meet the indication and may be denied.
Authorization required for pre‑operative bilateral MRI for biopsy‑proven malignant phyllodes
Prior authorization is required when MRI Breast Bilateral without and with contrast (CPT 77049 or HCPCS C8908) is requested pre‑operatively for malignant phyllodes; the request must document the prior tissue diagnosis.
Document the triggering reason and prior imaging when requesting MRI after screening
When requesting an MRI to complete screening after mammogram/US, include the triggering reason (e.g., treating provider request, radiologist recommendation, or specific mammogram/US finding) and any pertinent prior imaging to support medical necessity.
- Include radiologist report or treating provider request
- Attach relevant mammogram/ultrasound findings (BI‑RADS category)
Document lifetime‑risk calculation with accepted model for high‑risk MRI requests
When requesting screening MRI for high‑risk individuals, document the clinical lifetime‑risk calculation using an accepted model (Gail, Tyrer‑Cuzick, BCSC, BOADICEA/CanRisk, or BRCAPRO) to justify eligibility.
- Specify the risk model used and the calculated lifetime‑risk (≥20% required for MRI screening)
- If applicable, document gene mutation status or prior chest radiation details with age/timing
Documentation required for transmasculine supplemental screening requests
Requests for supplemental annual ultrasound and/or MRI screening in transmasculine individuals must include documentation supporting transmasculine status, surgical history (reduction mammoplasty or absence of chest surgery), age ≥25, and an objective lifetime‑risk calculation demonstrating ≥20% lifetime risk.
- Document surgical history (reduction mammoplasty, bilateral mastectomy, or none)
- Provide lifetime‑risk model and result (≥20%)
- Confirm patient age ≥25
Include prior mammogram/ultrasound results and BI‑RADS in documentation
Document prior diagnostic mammogram and/or breast ultrasound results including BI‑RADS category and clinical findings (e.g., palpable mass, skin changes, nipple symptoms) when requesting MRI or further imaging; lack of this information may jeopardize authorization.
- Include BI‑RADS category from prior imaging
- Describe clinical findings prompting imaging (palpable mass, discharge, skin change)
Frequency and Surveillance Intervals
Contrast Use Rules
Not Medically Necessary / Investigational
Routine CTA chest to evaluate recipient vessels for reconstruction is labeled NOT medically necessary. Gadolinium contrast is NOT medically necessary for implant integrity assessment in asymptomatic, average-risk individuals. In addition, a range of alternative breast imaging modalities (e.g., scintimammography, BSGI, PEM, thermography, impedance mammography, CT Breast/Cone Beam CT) are listed as investigational and are not supported for screening or diagnostic use.
The guideline states that routine CTA chest specifically for recipient vessel evaluation in free-flap reconstruction (e.g., to map recipient internal mammary vessels) is NOT medically necessary; an exception may be considered when prior cardiac/vascular surgery or known chest vascular anomalies could affect operative planning.
There is insufficient evidence to support routine pre-operative advanced imaging for pedicled flap reconstruction; therefore routine pre-operative imaging for pedicled flaps is not supported and is considered NOT medically necessary.
The guideline lists multiple investigational breast imaging modalities that are not covered for screening or diagnosis, including nuclear breast imaging (scintimammography, BSGI, PET mammography/PEM), thermography, impedance mammography, CT Breast (CPT 0633T–0638T), and Cone Beam CT Breast.
MRI has not been shown to reliably distinguish phyllodes tumor from fibroadenoma, and the guideline notes that MRI is not of value for that differential diagnosis; consequently MRI for that purpose is not supported and fine-needle aspiration (FNA) is not recommended for phyllodes diagnosis.
Background and Scope
These guidelines are evidence-based medical coverage policies developed by eviCore to guide determination of medical necessity and coverage for breast imaging services under Cigna-administered plans. They provide modality-, indication-, and code-specific guidance (including contrast rules and investigational exclusions) but are not treatment recommendations; the applicable benefit plan document governs final coverage decisions.
Definitions and Reference Terms
Prior Authorization — Scope and Requirements
Revision History
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