Currentsierra health and lifePolicy 2026T0375LL

Breast Imaging for Screening and Diagnosing Cancer – Commercial and Individual Exchange Medical Policy

Commercial and Individual Exchange medical policy defining medically necessary and not medically necessary breast imaging modalities (MRI, CT, MRE, MBI, tactile imaging, scintimammography, etc.), applicable clinical criteria for screening (including high-risk definitions and age thresholds), definitions, evidence review, guidelines citations, and applicable CPT/HCPCS codes for reference.

Policy Summary

Payersierra health and life

PolicyBreast Imaging for Screening and Diagnosing Cancer – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0375LL

Change TypeRevised coverage criteria; definitions updated; prior version archived

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument lifetime risk by an accepted model or specific family history and breast density category to support prior authorization and coverage decisions.

SourceLink

POLICY UPDATE CHANGES

Revised coverage criteria for MRI of the breast for individuals who are high risk for breast cancer.

Replaced wording on MRI for individuals with dense breast tissue without defined risk factors.

Added definition of 'Breast Composition Categories'.

Updated definition of 'Positron Emission Mammography (PEM)'.

Archived previous policy version 2026D0375KK.

12+Genetic mutations listed as indications

Coverage Summary

Scope: This commercial and individual exchange medical policy (Policy Number 2026T0375LL, effective February 1, 2026) defines medically necessary and not medically necessary breast imaging modalities and the clinical criteria for screening (including high-risk definitions and age/density thresholds).

Policy stance (mixed): Mammography is identified as the generally accepted standard screening modality. Breast MRI is covered (proven and medically necessary) for specified high-risk indications (detailed risk, genetic, age, and density criteria). Supplemental modalities such as ultrasound, contrast-enhanced mammography (CEM), and molecular breast imaging (MBI/BSGI) are discussed as adjuncts in certain situations but are generally considered based on risk and availability; several modalities including computed tomography (CT) of the breast, magnetic resonance elastography (MRE), computer-aided tactile breast imaging, and some molecular imaging procedures are listed as unproven / not medically necessary due to insufficient or inconsistent evidence.

Key thresholds and quick facts

Lifetime risk threshold>= 20% by validated family-history dependent models (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO)

Minimum screening ageBegin at age 40 (or 10 years prior to earliest relative diagnosis up to 3rd-degree relatives, whichever comes first; not before age 25)

Breast density requirementHeterogeneously dense (Category C) or Extremely dense (Category D) — screening beginning at age 40

Genetic / family-history early-start ruleScreening can begin at listed age or 10 years prior to age of diagnosis of youngest affected relative (up to 3rd-degree), whichever comes first, but not before age 25.

Medical-Necessity Criteria — When Breast MRI Is Covered

Proven and Medically Necessary: Breast MRI for High-Risk Individuals

Covered when ANY of the following high-risk criteria are met:

ANY of the following

ALL of the following
- Heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) — screening beginning at age 40
Prior thoracic radiation therapy between the ages 10 and 30 — screening starting at age 25 or 8 years after treatment, whichever is later
Lifetime risk estimated ≥ 20% as defined by models largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO) — screening beginning at age 40*>=20%
*Screening can begin at the listed age or starting 10 years prior to the age of diagnosis of the youngest relative (up to third-degree relatives), whichever comes first, but not before age 25.

Unproven and Not Medically Necessary

The following modalities/procedures are considered unproven and not medically necessary due to insufficient evidence:

ALL of the following

Computer-Aided Tactile Breast Imaging
Computed tomography (CT) of the breast
Magnetic Resonance Elastography (MRE) of the breast
MRI of the breast for individuals who do not meet the high-risk criteria above
Molecular Breast Imaging (e.g., Breast Specific Gamma Imaging, scintimammography, Positron Emission Mammography)

Provider Actions & Billing

Prior Authorization

Prior authorization expectation

Magnetic resonance imaging (MRI) screening exams for high-risk individuals may require prior authorization per the member’s benefit plan. Providers should obtain authorization before scheduling MRI breast screening when applicable to avoid claim denials or delays.

Prior authorization expectation applies to screening breast MRI for members meeting high-risk criteria as defined in this policy.
Verify member-specific benefits and prior authorization rules before performing MRI screening.

Documentation Required

Documentation may be required

Medical records documentation may be required to support the medical necessity of breast imaging services submitted for review. Maintain and submit relevant clinical records when requested.

Referenced Procedure Codes

Referenced Procedure Codes (for reference only; listing does not imply coverage)CPT

0422T	Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral.
0633T	Computed tomography, breast, including 3D rendering, unilateral; without contrast material.
0634T	Computed tomography, breast, including 3D rendering, unilateral; with contrast material(s).
0635T	Computed tomography, breast, including 3D rendering, unilateral; without contrast, followed by contrast material(s).
0636T	Computed tomography, breast, including 3D rendering, bilateral; without contrast material(s).
0637T	Computed tomography, breast, including 3D rendering, bilateral; with contrast material(s).
0638T	Computed tomography, breast, including 3D rendering, bilateral; without contrast, followed by contrast material(s).
76376	3D rendering with interpretation and reporting (concurrent supervision; not requiring independent workstation).
76377	3D rendering with interpretation and reporting (requiring independent workstation).
76391	Magnetic resonance (e.g., vibration) elastography.

1–10 of 15

1/2

HCPCSHCPCS

S8080

Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical.

No procedure/cpt/hcpcs codes listed in this partmixed

No codes listed

Background, Evidence, and Guideline Summaries

Background: Mammography remains the generally accepted standard for breast cancer screening and diagnosis, with supplemental imaging considered when needed to address limitations such as mammographic density or elevated risk.

Supplemental modalities: MRI and ultrasound are considered as supplemental screening tools based on individual risk and breast density; MRI is covered for defined high-risk indications. Evidence indicates supplemental MRI increases cancer detection (incremental CDR ~ 14.2–16.5 per 1000 screens) but may increase recalls and biopsies. Molecular techniques (MBI/BSGI/scintimammography/PEM) show relatively high sensitivity/specificity in some studies but have limited evidence of improved outcomes and higher radiation exposure. Evidence for breast CT, MRE, and tactile imaging is limited, heterogeneous, or insufficient to support routine screening use.

Society guideline summaries (informational)

Society recommendations summarized (informational; not direct coverage rules)

ANY of the following

SBI/ACR (2010): Breast ultrasound can be considered in high-risk women unable to undergo MRI; can be considered in women with dense breast tissue as adjunct to mammography
Informational

Revision History

02/01/2026revisedLatest

Revised coverage criteria for MRI of the breast for individuals who are high risk for breast cancer: added requirement for heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) with screening beginning at age 40; updated lifetime risk and family history criteria to indicate screening begins at age 40; clarified rule that screening can begin at listed age or 10 years prior to earliest affected relative (up to 3rd-degree), whichever comes first, but not before age 25; is_material: true

02/01/2026revisedLatest

Replaced wording 'MRI of the breast for individuals with dense breast tissue not accompanied by defined risk factors' with 'MRI of the breast for individuals who do not meet the criteria listed in the policy'; is_material: true

Policy Summary

Payersierra health and life

PolicyBreast Imaging for Screening and Diagnosing Cancer – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0375LL

Change TypeRevised coverage criteria; definitions updated; prior version archived

Effective DateFeb 1, 2026

Next Review Date

Key ActionDocument lifetime risk by an accepted model or specific family history and breast density category to support prior authorization and coverage decisions.

SourceLink

On This Page

Personal history with any of the following gene mutations

ATM — screening beginning at age 30*
*See early-start rule
BARD1 — screening beginning at age 40*
*See early-start rule
BRCA1 or BRCA2 — screening beginning at age 25
CDH1 — screening beginning at age 30*
*See early-start rule
CHEK2 — screening beginning at age 30*
*See early-start rule
NF1 — screening beginning at age 30*
*See early-start rule
PALB2 — screening beginning at age 30*
*See early-start rule
PTEN (Cowden syndrome) — screening beginning at age 30*
*See early-start rule
RAD51C — screening beginning at age 40*
*See early-start rule
RAD51D — screening beginning at age 40*
*See early-start rule
STK11 (Peutz-Jehgers syndrome) — screening beginning at age 30*
*See early-start rule
TP53 (Li-Fraumeni syndrome) — screening beginning at age 20

Family history criteria

At least one first-degree relative with a BRCA1 or BRCA2 mutation — screening beginning at age 40*
*See early-start rule
First-degree relative who carries a mutation in TP53 or PTEN genes (Li-Fraumeni, Cowden, Bannayan-Riley-Ruvalcaba, Peutz-Jehgers syndromes)
At least two first-degree relatives with breast or ovarian cancer — screening beginning at age 40*
*See early-start rule
One first-degree relative with bilateral breast cancer, or both breast and ovarian cancer — screening beginning at age 40*
*See early-start rule
First- or second-degree male relative diagnosed with breast cancer (father, brother/half-brother, uncle, grandfather) — screening beginning at age 40*
*See early-start rule

Revised MRI screening criteria for high-risk individuals

Coverage revised; MRI screening covered when ALL of the following are met:

ALL of the following

ONE of
- Lifetime risk estimated at greater than or equal to 20% as defined by models that are largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick, or BRCAPRO)>=20%
- Family history with at least one first-degree relative who has a BRCA1 or BRCA2 mutation
- Family history with at least two first-degree relatives with breast or ovarian cancer
- Family history with one first-degree relative with bilateral breast cancer, or both breast and ovarian cancer
- Family history with first- or second-degree male relative (father, brother/half-brother, uncle, grandfather) diagnosed with breast cancer
Breast composition includes heterogeneously dense breasts (Category C) or extremely dense breasts (Category D)
Added requirement for dense breasts (Category C or D) for certain screening contexts
Screening begins at age 40 when criteria met
Screening can begin at the listed age or 10 years prior to the age of diagnosis of the earliest relative (up to third-degree relatives), whichever comes first, but not before age 25

Documentation Required

Document risk estimate or family history

When screening or diagnostic MRI is requested based on elevated lifetime risk or family history, include an objective risk estimate or clear family history documentation in the record to support medical necessity.

Acceptable risk models include Gail, Claus, Tyrer-Cuzick, BRCAPRO, or other validated, family-history–based models showing lifetime risk ≥ 20% when used to justify screening MRI.
If risk is asserted based on family history rather than a risk-model score, document the relevant relatives, degree of relationship, ages at diagnosis, and any known pathogenic genetic variants.
For members with known deleterious gene mutations (e.g., BRCA1/2, TP53, PALB2, etc.), include genetic test reports and the mutation identified.

Billing Rule

CAD included with MRI CPT codes

Computer-aided detection (CAD) is included with breast MRI CPT codes 77048 and 77049; no separate reimbursement will be allowed for CAD when billed in conjunction with these codes.

Affected codes: 77048, 77049
If CAD is performed with these MRI codes, do not submit a separate line item for CAD reimbursement.

Evidence highlights

Incremental cancer detection rate (supplemental MRI)14.2 to 16.5 per 1000 screens (Zeng et al., systematic review)

CBBCT pooled performance (Yang et al./Uhlig) Sensitivity ~0.92, Specificity ~0.79, AUC 0.93 (CBBCT vs mammography; CE-CBBCT pooled sensitivity 0.899, specificity 0.788)

Molecular breast imaging pooled sensitivity/specificitySensitivity ~85%, Specificity ~84%–86% (older meta-analyses)

SNMMI/EANM 2022 guidanceMBI useful in detecting mammographically-occult cancer in women with dense breasts and elevated-risk women unable to undergo MRI

USPSTF 2024 statementEvidence insufficient to assess balance of benefits and harms of supplemental screening with ultrasound or MRI after negative screening mammogram, regardless of breast density

Breast Composition Categories: Category A — Almost entirely fatty; Category B — Scattered fibroglandular density; Category C — Heterogeneously dense; Category D — Extremely dense.

Molecular Breast Imaging (MBI) / BSGI / Scintimammography: Functional imaging using a radioactive tracer and a dedicated gamma camera to detect tissue activity; proposed as an adjunct to mammography to help detect mammographically occult lesions.

Magnetic Resonance Elastography (MRE): A phase-contrast–based MRI technique that measures mechanical properties (elastic modulus) of tissues to detect stiffness differences between normal and malignant tissue.

Positron Emission Mammography (PEM): High-resolution metabolic breast imaging using an FDG tracer with detectors integrated into a mammography system for emission imaging.