SelectHealth Upright/Weight-Bearing MRI Coverage

Coverage Criteria and Indications

inv-01: Covered Indications

Select Health covers breast tomosynthesis as a screening and diagnostic modality in the assessment and management of breast cancer when consistent with applicable guidelines and payer rules.

Coverage statement: Tomosynthesis is covered for screening and diagnostic use in assessment and management of breast cancer per Select Health commercial and CHIP policy

Policy affirms coverage for screening and diagnostic DBT

inv-02: Medically Necessary Indications (pre-surgical mapping)

SelectHealth considers fMRI medically necessary to identify vulnerable cortex substrate in pre-surgical evaluation of individuals with any of the following chronic conditions:

Medically necessary indications: brain tumors; epilepsy; vascular malformations

fMRI is used to identify vulnerable cortex substrate in pre-surgical evaluation for these conditions

inv-03: Experimental / Investigational

SelectHealth considers fMRI experimental and investigational for the diagnosis, monitoring, prognosis, or surgical management of the following (not all-inclusive):

Experimental/Investigational indications: Alzheimer's disease; Anoxic-ischemic brain injury; Attention-deficit hyperactivity disorder; Bipolar disorder; Chronic pain (including fibromyalgia); Disorders of consciousness; Multiple sclerosis; Parkinson's disease; Psychotic depression; Schizophrenia; Stroke/stroke rehabilitation; Trauma (e.g., head injury)

Effectiveness for these indications has not been established

inv-04: Covered Indications (MEG/MSI)

Select Health covers MEG/MSI when any of the following specific preoperative indications are met:

Covered Indications: 1) Preoperative surgical planning for individuals with intractable seizure disorders that have failed to respond to multiple antiepileptic regimens and where the seizure focus has not been adequately identified using traditional means.

Supports use in medically refractory epilepsy when standard localization methods are insufficient.

Covered Indications: 2) Preoperative brain function mapping for individuals with intracranial tumors.

Used to map functional areas prior to tumor resection.

Covered Indications: 3) Preoperative brain function mapping for individuals undergoing surgery for arteriovenous malformations (AVMs).

Used to guide surgical approach for AVM resection.

inv-05: Not Medically Necessary / Experimental

Coverage determination

Not covered: Select Health does NOT cover magnetic resonance-guided focused ultrasound in the management of essential tremor as it is considered experimental/investigational.

Applies to Select Health Commercial and CHIP per this section; Medicare/Medicaid guidance described separately.

inv-06: Not covered (Commercial and CHIP)

Coverage determination

Commercial/CHIP stance: Select Health does NOT cover MR neurography; current evidence is limited and has not proven clinical validity or defined clinical utility

Policy classifies MRN as experimental/investigational

inv-07: Program-specific coverage rules

Medicare and Medicaid guidance

Medicare/Medicaid coverage path: Coverage is determined by CMS for Medicare; if no CMS determination and InterQual criteria unavailable, SelectHealth Commercial policy applies. Select Health Community Care typically aligns with Utah Medicaid policy and InterQual.

Providers should consult CMS or state Medicaid resources for up-to-date determinations

inv-08: Covered Diagnostic MRI of the Breast

Select Health covers diagnostic MRI of the breast when a prior conventional mammogram and/or breast sonogram has been performed and MRI is expected to affect clinical management in any of the following circumstances:

Covered Diagnostic Indications A.1–A.8: 1. To confirm rupture of breast implants in asymptomatic members when screening ultrasonography shows rupture and implants are the result of a covered mastectomy. 2. To detect implant rupture in symptomatic members when ultrasonography shows no rupture and implants are the result of a covered mastectomy. 3. To detect local tumor recurrence in breast cancer patients post-mastectomy with reconstruction using an implant. 4. To detect local tumor recurrence in individuals with breast cancer who have radiographically dense breasts or scar tissue compromising mammography/ultrasonography. 5. To assess tumor location, size, and extent before/after neoadjuvant chemotherapy for determining eligibility for breast conservation therapy. 6. To detect extent of residual cancer in recently postoperative breast with positive margins when breast conservation and local re-excision are planned. 7. To localize primary occult breast cancer in individuals presenting with axillary node metastasis or distant metastasis without focal findings on exam or mammography/ultrasonography. 8. To guide localization for needle biopsy when suspicious lesions are detected only by contrast-enhanced MRI and cannot be visualized with mammography or ultrasonography.

Covered when MRI is expected to affect clinical management and prior conventional imaging performed.

inv-09: Covered Screening MRI of the Breast

Select Health covers MRI of the breast as screening for breast cancer when the member meets ANY of the following high-risk criteria:

Screening Indications B.1–B.3: 1. Known BRCA1 or BRCA2 mutation in patient or relatives. 2. Family history pattern in at least 2 first-degree relatives consistent with high probability of BRCA mutations or other hereditary breast cancer. 3. Women 30 years or younger with prior radiation therapy in childhood/adolescence to fields encompassing supraclavicular, mediastinal, axillary, or pulmonary hilar lymph nodes.

Screening MRI only for high-risk populations listed.

inv-10: Not Covered / Investigational MRI Uses

Select Health does NOT cover MRI of the breast for indications considered investigational:

Investigational / Not Covered C.1–C.7: 1. To confirm implant rupture in symptomatic individuals whose ultrasonography shows rupture, especially with implants >10 years. 2. To screen for breast cancer in members at average risk. 3. To evaluate breasts before biopsy to reduce surgical biopsies for benign lesions. 4. To differentiate benign from malignant breast disease, especially clustered microcalcifications. 5. To differentiate cysts from solid lesions (use ultrasound). 6. To provide early prediction of response to chemotherapy to guide regimen choice. 7. In women with dense breasts who are otherwise at low/average risk for breast cancer.

These uses are labeled investigational/not covered.

inv-11: Coverage and evidence summary

Coverage stance and clinical-context findings summarized from evidence sections:

Investigational exclusions: Select Health does NOT cover breast MRI for the following investigational circumstances: (1) to confirm implant rupture when ultrasound shows rupture (especially implants >10 years); (2) screening in average-risk women; (3) to evaluate breasts before biopsy to reduce surgical biopsies for benign lesions; (4) to differentiate benign from malignant disease such as clustered microcalcifications; (5) to differentiate cysts from solid lesions when ultrasound is indicated; (6) to provide an early prediction of chemotherapy response to guide regimen choice; (7) in women with 'dense' breasts who are otherwise low/average risk.

Exact investigational list taken verbatim from policy.

Situations with supporting evidence: Breast MRI may be useful and is supported by evidence in certain high-risk screening populations, preoperative mapping (to identify multicentric disease), evaluation of response to neoadjuvant chemotherapy, diagnosing chest wall involvement for posterior tumors, and detection of contralateral cancers in some scenarios; however, the net effect on outcomes varies by indication and evidence is limited for some uses.

Evidence summaries and limitations described in policy chunks.

inv-12: Commercial plan — MRgFUS

Not covered under Select Health Commercial plan when considered experimental/investigational

Commercial MRgFUS exclusion: Select Health does NOT cover MRI guided ultrasound ablation of uterine fibroids because published literature is limited and fails to answer questions regarding long-term efficacy and safety; meets plan definition of experimental/investigational.

Commercial coverage stance

inv-13: FDG-PET — Covered Indication (suspected FTD)

FDG-PET is covered only when ALL of the following are met

FDG-PET coverage prerequisites: 1) The patient has been evaluated by a recognized dementia expert (neurologist or neurology subspecialist). 2) The test is ordered by that neurologist or neurology subspecialist. 3) The patient has had a comprehensive clinical evaluation as defined by the AAN including history with informant, physical and mental status exam with cognitive scales or neuropsychological testing, laboratory tests, and structural imaging (MRI or CT).

FDG-PET coverage limited to evaluation when frontotemporal lobe dementia is suspected and routine testing failed to determine definitive diagnosis.

inv-14: Amyloid PET — Not Medically Necessary

Not covered

Amyloid PET (Amyvid): Amyloid (Amyvid) PET scans are not covered for the routine diagnosis of dementia and Alzheimer's disease because testing has failed to demonstrate clinical utility and is considered not medically necessary/experimental.

Also excludes other amyloid PET types (FBP-PET, PiB-PET) for this indication due to limited evidence.

inv-15: MRgFUS — Investigational / Not Covered

MRgFUS for uterine fibroids is considered investigational/unproven for this indication

MRgFUS investigational criteria: Available evidence is limited to small cohort and nonrandomized studies with short follow-up; randomized comparative trials versus hysterectomy, myomectomy, or uterine artery embolization are lacking; thus MRgFUS remains investigational/experimental pending further research.

CPT Category III codes 0071T and 0072T are listed as investigational/not covered.

inv-16: FDG-PET medical necessity

Covered when ALL of the following are met

FDG-PET coverage prerequisites: 1) Patient has been evaluated by a recognized dementia expert (neurologist or neurology subspecialist). 2) The test is ordered by that neurologist or neurology subspecialist. 3) The patient has had a comprehensive clinical evaluation as defined by the American Academy of Neurology (medical history including informant and ADL assessment; physical and mental status exam with cognitive scales or neuropsych testing; laboratory tests; and structural imaging such as MRI or CT).

Also limited to evaluation when frontal temporal lobe dementia is suspected and other routine testing failed to determine a definitive diagnosis.

inv-17: Amyloid PET - Not covered

Amyloid PET coverage stance: Amyloid PET (Amyvid and similar amyloid tracers) is considered experimental/investigational and not medically necessary for routine diagnosis of dementia/Alzheimer's disease due to lack of demonstrated clinical utility.

Select Health does not cover for routine diagnosis; other amyloid PET tracers (FBP-PET, PiB-PET) are also not covered for this indication.

inv-18: Total Body MRI — Coverage Criteria

Covered for surveillance when ALL of the following are met

Li-Fraumeni surveillance coverage: Patient is at-risk for Li-Fraumeni syndrome (known TP53 mutation or family at increased risk) AND total body MRI is performed for cancer surveillance

Select Health covers total body MRI for cancer surveillance in patients with Li-Fraumeni syndrome as clinically proven when billed using CPT 76498.

inv-19: Coverage for MM and MGUS

Covered when used for the assessment, staging, or diagnosis of multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS).

Main coverage rationale: Total body MRI is considered a proven technology for assessing MM and MGUS with improved clinical validity compared with standard skeletal survey x-rays; studies demonstrate higher sensitivity and specificity for detecting myelomatous lesions and metastases.

Evidence supports tb‑MRI for staging and detection of extraskeletal lesions.

inv-20: Not covered — experimental/investigational

Not covered for evaluation of chronic back and neck pain

Primary coverage statement: Select Health does NOT cover upright/weight-bearing, dynamic kinetic magnetic resonance imaging for evaluation of chronic back and neck pain

The medical literature has failed to prove clinical utility; classified as experimental/investigational by the plan.

inv-21: Not Covered (Commercial & CHIP)

Select Health Commercial and CHIP coverage determination

Not covered - Experimental/Investigational: Upright/weight-bearing, dynamic kinetic MRI is considered experimental/investigational because the medical literature has failed to prove clinical utility in evaluation of chronic back and neck pain.

Applies to Commercial and CHIP plans.

No explicit exclusions for Upright/Weight‑Bearing, Dynamic Kinetic MRI are provided in the supplied policy text beyond the plan's overall stance that this modality is not covered for evaluation of chronic back and neck pain. The table of contents entry and related notes list the procedure but do not enumerate separate exclusion clauses specific to other modalities or indications in the excerpts provided.

Within the portions of the document available, there are no explicit modality‑ or indication‑specific exclusions listed beyond those included in the policy sections (for example, investigational uses described elsewhere); this section does not state additional modality/indication exclusions. Providers should consult the applicable coverage sections for modality‑specific determinations.

Select Health considers functional MRI (fMRI) medically necessary only for pre‑surgical mapping to identify vulnerable cortex for conditions such as brain tumors, epilepsy, and vascular malformations. fMRI is considered experimental/investigational (not medically necessary) for a range of neurologic and psychiatric indications including Alzheimer's disease, ADHD, chronic pain, schizophrenia, stroke rehabilitation, disorders of consciousness, multiple sclerosis, Parkinson’s disease, psychotic depression, and traumatic brain injury, and therefore is not covered for those purposes.

Select Health covers MEG/MSI only for specific preoperative uses: 1) preoperative surgical planning for medically intractable epilepsy when standard localization is inadequate; 2) preoperative brain function mapping for intracranial tumors; and 3) preoperative mapping for arteriovenous malformations (AVMs). Any other uses, such as functional neurological or psychological testing, are considered experimental/investigational and not covered.

Magnetic resonance‑guided focused ultrasound (MRgFUS) for essential tremor or for uterine fibroid ablation is classified as experimental/investigational and not covered by Select Health Commercial and CHIP plans. The policy cites limited evidence, lack of randomized comparative trials, and insufficient long‑term data as the rationale for excluding MRgFUS as a covered treatment option.

Select Health considers MR neurography (MRN) investigational/experimental/unproven for the listed indications and does not cover MRN under the Commercial and CHIP plans. The policy notes that current evidence is limited, clinical validity has not been proven for many conditions, and clinical utility has not been defined; billing with the unlisted MRI CPT (e.g., 76498) for these indications may be denied.

Select Health explicitly lists investigational uses of breast MRI that are not covered (C.1–C.7). These include: confirming implant rupture when ultrasound already shows rupture (especially implants >10 years), screening average‑risk women, pre‑biopsy evaluation intended to reduce benign surgical biopsies, differentiating clustered microcalcifications, differentiating cysts from solid lesions when ultrasound is indicated, early prediction of chemotherapy response to guide regimen choice, and use in women with dense breasts who are otherwise low/average risk.

In addition to the investigational list above, the policy states that MRI of the breast is not covered for the seven specific circumstances enumerated in section C (items C.1–C.7). These circumstances are treated as investigational and therefore excluded from coverage under the Commercial and CHIP policy.

Select Health's Commercial plan explicitly excludes MRgFUS for uterine fibroid ablation when it is characterized as experimental/investigational; the policy states that MRgFUS is not covered under the Commercial plan because evidence is limited and long‑term efficacy and safety compared with standard alternatives remain unproven.

The policy highlights evidence gaps for MRgFUS: randomized comparative trials versus hysterectomy, myomectomy, or uterine artery embolization are lacking, sample sizes and follow‑up are limited, and long‑term outcomes and durability have not been established. Because of these deficiencies, MRgFUS is excluded as a standard alternative and remains investigational.

Select Health does not cover amyloid PET tracers (including Amyvid and the HCPCS Q‑codes for amyloid agents) for the routine diagnosis of dementia or Alzheimer’s disease. The policy states amyloid PET is considered not medically necessary/experimental because testing has not demonstrated clinical utility; a revision clarified the Commercial plan exclusion for Amyvid PET in the opening paragraph.

The revision history clarifies that for the Commercial plan, Amyvid PET scans are explicitly excluded for routine dementia diagnosis: “Select Health does NOT cover amyloid (Amyvid) PET scans for the routine diagnosis of dementia and Alzheimer's disease…,” reinforcing the policy's noncoverage stance for amyloid imaging in routine dementia evaluation.

The inclusion or exclusion of procedure and HCPCS/CPT codes in this policy is for informational purposes only and does not guarantee member coverage. Final coverage and reimbursement determinations depend on the member’s individual benefit plan and eligibility in effect at the time of service; providers should verify benefits and obtain prior authorization as required.

Select Health states that upright/weight‑bearing and dynamic kinetic MRI is not covered for evaluation of chronic back and neck pain. The literature reviewed is described as insufficient to demonstrate that upright MRI is more accurate than conventional MRI or that it impacts diagnostic or therapeutic management; consequently the procedure is classified as investigational for this indication.

For both Select Health Commercial and CHIP plans the policy specifies that upright MRI (weight‑bearing/dynamic kinetic MRI) is considered experimental/investigational and not covered for the evaluation of chronic back and neck pain. Because it is categorized as investigational, prior authorization is not applicable and claims may be denied.

Top-Level Covered Indications (by modality)

inv-159: Screening and diagnostic evaluation of breast abnormalities (DBT/mammography)

Indications: Screening in general population as alternative to FFDM and diagnostic follow-up for abnormalities seen on mammography; triage or supplemental imaging

Multiple studies reviewed support DBT for screening and diagnostic use; policy covers both screening and diagnostic modalities.

inv-160: Pre-surgical functional mapping to identify vulnerable cortex substrate (fMRI)

Pre-surgical mapping indications: brain tumors; epilepsy; vascular malformations

Used to identify vulnerable cortex substrate for surgical planning

inv-161: Preoperative mapping/localization for epilepsy, brain tumors, and AVMs (MEG/MSI)

Procedure and Billing Codes

Not covered CPT Codes (from Breast Thermography policy section present in window)CPTNot Covered

93740

Temperature gradient studies

CPT CODESCPT

77067	Screening mammography, bilateral (2-view study of each breast), including computer- aided detection (CAD) when performed
77061	Digital breast tomosynthesis; unilateral
77062	Digital breast tomosynthesis; bilateral
77063	Screening Digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)

HCPCS / ICD-10 CODESmixed

G0202	Screening mammography, producing direct digital image, bilateral, all views.
G0204	Diagnostic mammography, producing direct 2-d digital image, bilateral, all views.
G0206	Diagnostic mammography, producing direct 2-d digital image, unilateral, all views.
G0279	Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206).
D24.9	Benign neoplasm of unspecified breast.
D48.60	Neoplasm of uncertain behavior of unspecified breast.
D48.61	Neoplasm of uncertain behavior of right breast.
D48.62	Neoplasm of uncertain behavior of left breast.
D49.3	Neoplasm of unspecified behavior of breast.
N63	Unspecified lump in breast.

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Covered CPT CodesCPTCovered

70554	Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
70555	Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
96020	Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report

Covered CPT Codes (MEG/MSI)CPTCovered

95965	Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization)
95966	for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization)
95967	for evoked magnetic fields, each additional modality (e.g., sensory, motor, language, or visual cortex localization) (List separately in addition to code for primary procedure)

CPT CODESCPT

0398T

Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed

HCPCS CODESHCPCS

C9734

Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (MR) guidance

Not covered / Investigational CPT CodesCPTNot Covered

76498

Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)

CPT CODES (MR Neurography)CPT

76498

Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)

HCPCS CODESHCPCS

No codes listed

CPT Codes for breast MRICPT

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

HCPCS Codes for breast MRIHCPCS

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

HCPCS breast MRI codesHCPCS

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

Investigational / Not Covered CPT Category III CodesCPTNot Covered

0071T	Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue
0072T	Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue

HCPCS CodesHCPCS

No codes listed

CPT CODESCPT

78608	Brain imaging, positron emission tomography (PET); metabolic evaluation
78609	; perfusion evaluation
78811	Positron emission tomography (PET) imaging; limited area (e.g., chest, head/neck)
78814	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (e.g., chest, head/neck)

HCPCS CODESHCPCS

A9552	Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
Q9982	Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries
Q9983	Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries
A9586	Florbetapir F18, diagnostic, per study dose, up to 10 millicuries

Covered CPT Codes for Total Body MRI (Li-Fraumeni syndrome)CPTCovered

76498

Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)

HCPCS CodesHCPCS

No codes listed

CPT CODESCPTCovered

76498

Unlisted magnetic resonance procedure (e.g., diagnostic, interventional)

HCPCS CODESHCPCS

No codes listed

No procedure or CPT/HCPCS codes provided for upright/weight-bearing MRI in this sectionmixed

No codes listed

CPT CodesCPT

76498

Unlisted magnetic resonance procedure (eg. diagnostic, interventional)

HCPCS CodesHCPCS

No codes listed

Total leiomyomata volume differentiation — less than 200 cc vs greater or equal to 200 cc

CPT category III codes0071T: focused ultrasound ablation of uterine leiomyomata, MR guidance; total leiomyomata volume less than 200 cc

CPT category III codes0072T: focused ultrasound ablation of uterine leiomyomata, MR guidance; total leiomyomata volume greater or equal to 200 cc

Threshold usePolicy distinguishes treatment reporting/coverage status by total leiomyomata volume: <200 cc versus ≥200 cc

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization and Benefit Verification

Prior authorization and benefit verification requirements vary by product line. For Select Health Medicare (CMS) and Select Health Community Care (Medicaid), coverage determinations are made by CMS or by State Medicaid policy (including use of InterQual); when a CMS/state determination does not exist and InterQual is not available, Select Health commercial policy applies. Providers must verify member benefits and obtain any required prior authorization from Select Health before scheduling services. Benefits and eligibility are determined by the member's individual benefit plan at the time services are rendered.

Verify member benefits and obtain required prior authorization with Select Health prior to service.
Medicare: Follow CMS coverage determinations; if none exist, Select Health commercial policy applies.
Medicaid: Follow State Medicaid/CMS guidance and InterQual when applicable; Select Health Community Care typically aligns with Utah Medicaid.
When coverage is uncertain, obtain prior authorization and document rationale.

Explicitly Not Covered / Investigational Uses

Within the provided chunks summarizing prior reviews and updated evidence, there are no explicit modality/indication combinations additionally listed as not covered beyond the investigational exclusions already stated; earlier reviews had insufficient evidence for some technologies but updated assessments modified coverage where evidence supported it.

Transcranial MR‑guided focused ultrasound for essential tremor is specifically listed as not covered because it is considered experimental/investigational. Similarly, MRgFUS for uterine fibroid ablation is not covered under the Commercial plan due to insufficient evidence and unresolved questions regarding long‑term efficacy and safety.

MR neurography for the clinical indications reviewed is designated as investigational/experimental/unproven and therefore not covered under Select Health Commercial and CHIP policies; billing for these indications may be denied.

The policy enumerates several breast MRI uses that are considered investigational and not covered — including screening of average‑risk women, pre‑biopsy replacement intended to reduce benign surgical biopsies, differentiation of clustered microcalcifications, cyst versus solid lesion differentiation when ultrasound is indicated, early prediction of chemotherapy response to guide regimen choice, and certain implant‑rupture confirmations. These investigational scenarios may be denied if billed.

MRI‑guided ultrasound ablation (MRgFUS) of uterine fibroids is listed as not covered under the Commercial plan because the literature is limited, lacks randomized comparative trials, and does not provide sufficient long‑term follow‑up data to establish safety, efficacy, and comparative effectiveness.

Background and Scope

This brief was extracted from the Select Health imaging policy table of contents where Upright/Weight‑Bearing, Dynamic Kinetic MRI is listed (Policy #312) and shows the policy was last reviewed on 04/17/25. The provided chunks did not contain additional clinical background for upright MRI beyond the listing and the not‑covered determination.

The policy reiterates that the presence or absence of codes in the document does not by itself ensure coverage: inclusion or exclusion of codes is informational only and coverage depends on the member’s individual benefit plan and eligibility; providers should verify benefits and prior authorization requirements with the payer.

Key Definitions and Terms

Upright/Weight-Bearing, Dynamic Kinetic MRI — definition

DefinitionUpright/Weight‑Bearing, Dynamic Kinetic MRI: an MRI device and technique that enables partial or full weight‑bearing and simultaneous kinetic maneuvers of the patient's whole body or an individual body part (eg, FONAR system)

Typical vendor/exampleFONAR Corporation device enabling upright/weight‑bearing imaging and kinetic maneuvers

Clinical rationaleIntended to image conditions under physiologic load or motion that may not be evident in recumbent MRI

Digital breast tomosynthesis (DBT) — definition

DefinitionDigital breast tomosynthesis (DBT): a tomographic application of digital mammography where the x‑ray tube acquires multiple low‑dose exposures through a limited arc and reconstructs thin high‑resolution slices for display

Coverage stance

Prior Authorization Rules and Plan Alignment

Prior Authorization

DBT/mammography: follow CMS for Medicare; verify commercial prior auth

Follow CMS determinations for Medicare DBT/mammography coverage; for commercial plans, verify and obtain prior authorization per Select Health commercial rules when applicable.

Prior Authorization

fMRI: verify benefits; prior authorization may be required

Coverage for fMRI depends on the member’s benefit at time of request; prior authorization or benefit verification may be required — verify before scheduling.

Prior Authorization

MEG/MSI: obtain prior authorization per member plan

Prior authorization and benefit verification are required per the member’s plan for MEG/MSI; for Medicare members follow CMS determinations where applicable.

Prior Authorization

Contrast and Technical Rules

Billing Rule

No explicit contrast rules for upright MRI or tomosynthesis in document

No specific contrast rules are provided for upright/weight‑bearing or tomosynthesis in the policy sections reviewed.

Note

Frequency Limits and Related Key Values

Digital breast tomosynthesis / mammography — frequency limit key-value

Frequency guidanceDigital breast tomosynthesis and screening/diagnostic mammography CPT/HCPCS codes listed in policy (eg, 77061, 77062, 77063, 77067, G0202, G0204, G0206, G0279); follow applicable payer scheduling and benefit rules for screening intervals

Provider actionProviders should verify member benefits and applicable prior authorization rules for DBT or mammography prior to scheduling

NotePolicy lists DBT as covered for screening and diagnostic use; frequency limits should align with member benefit plan and CMS guidance where applicable

MRI — frequency limit key-value

Frequency guidanceMRI frequency limits not specified in policy; use is determined by clinical indication and member benefit plan—providers should verify benefits/prior authorization

Policy Revisions and Change Log

2025-05-29clarificationLatest

Commercial plan policy clarified that amyloid (Amyvid) PET scans are excluded in the opening paragraph of the criteria for routine diagnosis of dementia and Alzheimer's disease.

coverage_statement

Billing/Coding information notes that services are covered for the conditions outlined in the policy.