CurrentMass General Brigham Health PlanPolicy 085

Medical Necessity Guidelines — Breast Imaging

Guidelines governing medical appropriateness and prior authorization requirements for breast imaging (mammography, breast MRI, ultrasound, PET) across Mass General Brigham Health Plan lines of business and affected providers.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines — Breast Imaging

Policy CodePolicy 085

Change TypeNo material change

Effective DateDec 1, 2024

Next Review Date

Key ActionObtain prior authorization when required by the member's line of business (Medicare Advantage and Commercial/QHP) using InterQual criteria and submit documentation aligning the request to CMS NCDs/LCDs or InterQual as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

YesPrior authorization required (Medicare Advantage)

NoPrior authorization not required (ACO/One Care/SCO)

YesPrior authorization required (Commercial/QHP)

InterQualMedical necessity criteria

InformationalProcedure codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage rules and medical necessity

Line-of-business coverage determination logic

Coverage and medical necessity determinations are based on the following sources and applied per line of business:

Medicare Advantage: Apply CMS NCDs, LCDs, and LCAs first; when those lack sufficient specificity, apply plan-specific additional coverage criteria and InterQual criteria for MRI and PET breast imaging.

Mass General Brigham Health Plan uses CMS guidance (NCDs, LCDs, LCAs) as the basis for Medicare Advantage medical necessity determinations; InterQual is used for breast MRI and PET when CMS guidance lacks sufficient specificity.

Mass General Brigham ACO: Use MassHealth guidance for medical necessity; at time of review, ACO does not require prior authorization for mammogram or breast ultrasound; follow MassHealth guidelines where present (e.g., Breast MRI guidance).

One Care and SCO: Apply Medicare criteria first; if Medicare criteria are not met, apply MassHealth criteria. Prior authorization is not required for One Care and SCO.

Commercial and Qualified Health Plans: Medical necessity determined using InterQual criteria; prior authorization required. InterQual criteria are customized to remove mammography authorization when breast MRI is approved.

Access InterQual criteria via the provider website (MassGeneralBrighamHealthPlan.org).

Specific procedure codes listed as Not covered vary by line of business. For Medicare Advantage the document lists G0252 and S8042 as not covered. For the Mass General Brigham ACO the document lists C8903, C8905, C8906, C8908, and S8042 as not covered. For One Care and SCO the document lists S8042 as not covered. For Commercial and Qualified Health Plans prior authorization is required and coverage is determined using InterQual criteria, with not-covered codes varying per line of business as noted above.

The procedure codes included in this policy are provided for informational purposes only. Inclusion of a code does not constitute or imply coverage or reimbursement; services must meet the applicable medical necessity criteria (CMS NCDs/LCDs, MassHealth guidance, or InterQual criteria as specified by line of business) to be considered covered.

Breast MRI and PET appropriate use rules

Breast MRI and PET appropriate use rules: Indications for breast MRI and PET are evaluated using InterQual criteria (customized by the plan); mammography does not require prior authorization and is exempted from InterQual authorization rules when MRI is approved.

Procedure codes (informational)

Informational procedure codesmixed

77046	Magnetic resonance imaging, breast, without contrast material; unilateral.
77047	Magnetic resonance imaging, breast, without contrast material; bilateral
77048	Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral.
77049	Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral.
78811	Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck).
C8903	Magnetic resonance imaging with contrast, breast; unilateral.
C8905	Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral.
C8906	Magnetic resonance imaging with contrast, breast; bilateral.
C8908	Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral.
G0252	PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes).

1–10 of 11

1/2

Not-covered codes are specified separately by line of business and appear in the Exclusions and Codes sections. At the time of this policy's review the document lists the following not-covered codes by plan: Medicare Advantage: G0252, S8042; Mass General Brigham ACO: C8903, C8905, C8906, C8908, S8042; One Care and SCO: S8042. Providers should refer to the Codes section for the full list of codes included for informational purposes and to confirm whether a specific code is listed as not covered for a particular line of business.

Prior authorization, documentation, and denial risk

Prior Authorization

Medicare Advantage prior authorization

Prior authorization required for Medicare Advantage plan members for certain breast imaging services per plan variation. Mass General Brigham Health Plan uses CMS guidance (NCDs, LCDs, LCAs, Medicare manuals) for medical necessity determinations; when CMS guidance is insufficient, InterQual criteria are applied (with mammography authorization removed where applicable). Affected codes: G0252, S8042.

NCD: Percutaneous Image-Guided Breast Biopsy 220.13
LCDs: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography (L33950) and Breast Echography (Sonography)/Breast MRI/Ductography (L33585)
InterQual used for MRI and PET imaging of the breast; mammography authorization removed

Note

ACO prior authorization

Mass General Brigham ACO members do not require prior authorization for breast imaging services. Mass General Brigham Health Plan uses MassHealth guidance for medical necessity determinations for ACO members; when MassHealth guidance is absent, the plan's medical policies are used.

Which services require prior authorization

Prior Authorization

Prior authorization requirement by modality and line of business

Prior authorization is required for MRI, PET, and other breast imaging as specified for Medicare Advantage and for Commercial/QHP plans; prior authorization is not required for ACO, One Care, or SCO.

Medicare Advantage: prior authorization required and CMS guidance forms basis for determinations.
Commercial/QHP: prior authorization required; InterQual used to assess MRI/PET and other specified imaging.
ACO/One Care/SCO: prior authorization not required.

MRI contrast and related rules

Billing Rule

Breast MRI contrast coding and InterQual application

MRI breast procedure codes distinguish imaging with and without contrast; InterQual criteria apply to MRI and the plan customizes InterQual to remove mammography authorization when MRI is approved.

Examples of MRI codes listed (informational): 77046, 77047, 77048, 77049; CMS/plan-specific codes: C8903, C8905, C8906, C8908.
Policy notes that code lists are informational and inclusion does not guarantee coverage.

Policy background and scope

Mass General Brigham Health Plan determines medical appropriateness for breast imaging using a hierarchy of sources applied per line of business. For Medicare Advantage, the plan applies CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) first; when those sources lack sufficient specificity, the plan applies additional plan-specific criteria and InterQual criteria for MRI and PET imaging of the breast. For Commercial and Qualified Health Plans, medical necessity is determined using InterQual criteria (the plan has customized InterQual to remove authorization requirements for mammography when breast MRI is approved). For ACO, One Care, and SCO lines of business the plan follows MassHealth or Medicare guidance as applicable; ACO, One Care, and SCO do not require prior authorization for breast imaging per this policy. Providers should submit documentation that aligns the request with the applicable NCDs/LCDs, MassHealth guidance, or InterQual criteria depending on the member's line of business.

Key terms

InterQual criteria — definition and role

DefinitionInterQual criteria are a set of clinical decision‑support criteria used by the plan to determine medical necessity for breast imaging (MRI, PET, and other modalities).

Plan useMass General Brigham Health Plan applies InterQual for review of breast MRI and PET when CMS NCDs/LCDs lack sufficient specificity to ensure consistent medical review and coverage decisions.

CustomizationInterQual criteria have been customized by the plan to remove recommendations that would require authorization of mammography (mammography does not require prior authorization for any plan).

AccessInterQual criteria used for Commercial and Qualified Health Plans are available via the Mass General Brigham Health Plan provider website (InterQual® Criteria Lookup).

ScopeInterQual is used primarily for MRI and PET breast imaging appropriateness determinations; mammography is exempted from authorization rules when MRI is approved.

Policy version and changes

2026-05annual_updateLatest

Annual update: reformatted policy, updated LCD links, clarified coverage information for some codes, and updated references.

2026-01ad_hoc_update

Ad hoc update: updated prior authorization table and added variation for One Care and SCO members.

2025-09annual_update