Magnetic Resonance Imaging (MRI) of the Breast
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Defines clinical indications, coverage stance, coding and payment guidance for breast MRI for Highmark Pennsylvania commercial members; applies to professional and facility claims and outpatient place of service, with special inpatient exceptions.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically Necessary Indications
Covered when ANY ONE of the following is present
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
from policy indications
Experimental/Investigational / Not Medically Necessary
Not covered (considered experimental/investigational)
policy statement
code 0159T listed
MRI studies of the breast that are not specifically listed in the policy’s medically necessary indications are considered experimental/investigational (E/I) and are not covered. This applies regardless of place of service; coverage is limited to the indications enumerated as medically necessary in the policy.
Computer-aided detection for breast MRI (CPT code 0159T) is considered experimental/investigational and is not covered. In addition, any MRI of the breast performed for indications not listed as medically necessary in this policy is considered E/I and non-covered.
Covered Indications
High-risk screening and problem-solving indications listed under medical necessity
Top-level grouped indications listed under medical necessity
Coding
| 77058 | MRI breast unilateral |
| 77059 | MRI breast bilateral |
| 77058 | MRI breast unilateral |
| 77059 | MRI breast bilateral |
| 0159T | Computer-aided detection (CAD) for MRI of the breast |
| C8908 | Outpatient MRI related HCPCS C-codes (listed in policy) |
| C8904 | Outpatient MRI related HCPCS C-codes (listed in policy) |
| C8905 | Outpatient MRI related HCPCS C-codes (listed in policy) |
| C8906 | Outpatient MRI related HCPCS C-codes (listed in policy) |
| C8907 | Outpatient MRI related HCPCS C-codes (listed in policy) |
Provider Actions / Billing Rules
Pre-payment application for Professional claims
This policy is applied on a pre-payment basis for professional claims; process professional (non-facility) MRI of the breast claims as pre-payment. Refer to operational guidelines for post-payment applications noted in the bulletin.
- Applies to Professional claims (pre-payment)
Provider actions — documentation and member agreements
Follow the policy’s provider requirements: obtain and retain advance written notice and signed cost agreement when a service is determined experimental/investigational and the member agrees to assume financial responsibility; submit documentation to support medical necessity when required (see CT vs MRI same-day rule).
- Maintain signed advance written notice and cost agreement in provider records if member agrees to pay for E/I service.
- Submit supporting documentation to establish medical necessity when requested.
Same-day MRI and CT — CT paid unless medical necessity for both documented
When both MRI and CT of the same anatomic area are performed the same day, payment is made for the CT; the MRI will only be paid if supporting documentation is submitted to establish medical necessity for both studies.
- If claiming payment for same-day MRI in addition to CT, include documentation demonstrating medical necessity for both procedures.
Denial risk for services not meeting criteria — E/I designation and member billing rules
Services that do not meet this policy’s criteria will be considered experimental/investigational (E/I) and may be denied. A network provider may bill the member only after providing advance written notice with an estimate of cost and obtaining the member’s signed agreement assuming financial responsibility; keep the signed agreement in records.
- E/I services are not covered regardless of place of service.
- Provider must give advance written notice and obtain written member agreement before billing the member.
Prior Authorization / Claim Edits
MRI — professional pre-payment and documentation requirement for same-day CT
Policy is applied on a pre-payment basis for professional claims; documentation may be required to justify payment when MRI and CT of the same anatomic area are performed on the same day.
- Professional claims are pre-payment; facility guidance is provided separately.
- If MRI and CT are same-day for same anatomy, submit documentation to justify payment for MRI.
Contrast Material Payment Rules
Contrast payment rule — contrast reimbursed in addition to MRI when provider-administered outside hospital/skilled facility
Payment is made for contrast material in addition to the MRI procedure when the contrast is used with an eligible imaging procedure and is administered by the health care professional in a setting other than a hospital or skilled facility.
Not Covered
Not covered: Computer-aided detection (0159T) for MRI of the breast, including computer algorithm analysis of MRI image data for lesion detection/characterization and pharmacokinetic analysis with physician review, is considered experimental/investigational and therefore non-covered. Also explicitly non-covered are MRI studies of the breast for any indications not listed in the policy’s medically necessary criteria.
Background
Breast MRI produces detailed cross-sectional images and is a complementary imaging modality rather than a routine screening tool for the general population. It is used for specific high-risk screening and problem-solving indications such as evaluating known hereditary risk (including BRCA mutations and related syndromes), assessing the presence or recurrence of breast cancer, local staging or preoperative mapping (including evaluation for multicentric disease or chest wall invasion), detecting occult primary tumors when mammography and exam are negative, assessing response to neoadjuvant chemotherapy, evaluating implant rupture, and localizing lesions prior to MRI-guided biopsy when other methods cannot localize the abnormality. Risk estimation tools referenced by the policy include the Claus, modified Gail, Tyrer-Cuzick and BRCAPRO models.
Definitions
Revision History
Issue date updated to September 26, 2016 and policy effective date reflected as September 26, 2016.
Policy originally effective March 7, 2016 (initial publication of MRI of the Breast policy X-44).
Clinical Policy Management Committee and consultants review noted in February 2016 leading to new criteria for MRI of the Breast (document change noted).
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