CurrentUnitedHealthcarePolicy CS010NE.X

Breast Imaging for Screening and Diagnosing Cancer (for Nebraska Only)

Defines UnitedHealthcare Community Plan medical policy (Nebraska only) for supplemental and diagnostic breast imaging modalities, specifying medically necessary indications (not including routine mammography) for breast MRI and listing modalities considered unproven/not medically necessary. Includes coding references and documentation requirements.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Imaging for Screening and Diagnosing Cancer (for Nebraska Only)

Policy CodePolicy CS010NE.X

Change TypeRevised MRI coverage criteria; added density requirement

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain and document qualifying risk model results, family history details including degree of relatives and ages at diagnosis, and breast composition category (C or D) to support MRI screening medical necessity.

POLICY UPDATE CHANGES

Added criterion requiring 'heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) (screening beginning at age 40)' for MRI screening in high-risk individuals.

Added language indicating screening begins at age 40 for specified family-history-based high-risk criteria.

Updated timing rule to allow screening to begin at the listed age or 10 years prior to the age of diagnosis of the youngest relative (up to third-degree), whichever comes first, but not before age 25.

Replaced '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]'.

Added definition of 'Breast Composition Categories' and updated definition of 'Positron Emission Mammography (PEM)'.

Updated Clinical Evidence and References sections to reflect current information.

1State-specific policy (Nebraska only)

>=20%Risk threshold for MRI screening

25Youngest listed MRI start age (TP53)

1Material policy updates (MRI criteria)

Category C/DNew required density criterion

Coverage Summary

This Nebraska-specific UnitedHealthcare Community Plan policy (Policy Number CS010NE.X, effective April 1, 2026) defines medically necessary indications for supplemental and diagnostic breast imaging, with a revised focus on MRI screening for individuals at high risk for breast cancer. The policy applies to Nebraska only and excludes routine preventive screening with conventional mammography.

Key high-level thresholds in the revised criteria include a lifetime risk estimate threshold of ≥ 20% (per models largely dependent on family history such as Gail, Claus, Tyrer-Cuzick, or BRCAPRO), a required breast composition of heterogeneously dense (Category C) or extremely dense (Category D) for MRI screening beginning at age 40, and an operational rule allowing screening to start at the listed age or 10 years prior to the age of diagnosis of the youngest affected relative (up to third-degree), whichever comes first, but not before age 25.

Key thresholds for MRI screening

Lifetime breast cancer risk threshold>= 20% (per models such as Gail, Claus, Tyrer-Cuzick, BRCAPRO)

Age for family-history-based earlier screeningStart 10 years prior to age of diagnosis of the youngest affected relative (up to 3rd-degree), but not before age 25

Breast composition requirementHeterogeneously dense (Category C) or Extremely dense (Category D)

Youngest listed MRI start age25 (for TP53 mutation carriers)

Medically Necessary Criteria

Medically Necessary: Breast MRI for High-Risk Individuals

Breast MRI is proven and medically necessary for individuals who are high risk for breast cancer defined by ANY of the following:

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, or BRCAPRO)≥ 20%

Not Medically Necessary / Unproven

The following imaging modalities are unproven and not medically necessary due to insufficient evidence of efficacy:

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 criteria above
Molecular Breast Imaging (e.g., Breast Specific Gamma Imaging, scintimammography, Positron Emission Mammography)

CPT/HCPCS Codes Referenced

CPT/HCPCS codes referencedmixed

0422T	Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral
0633T	Computed tomography, breast, including 3D rendering, unilateral; without contrast
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... not requiring image postprocessing on an independent workstation
76377	3D rendering ... requiring image postprocessing on an independent workstation
76391	Magnetic resonance (e.g., vibration) elastography

1–10 of 16

1/2

No specific billing/codes in this partmixed

No codes listed

Provider Actions and Requirements

Prior Authorization

MRI screening prior authorization implication

Coverage for breast MRI screening is limited to individuals who meet the revised high‑risk and breast density criteria; providers should obtain and document qualifying risk model results and family history (degree of relatives and ages at diagnosis) to support medical necessity and prior authorization.

qualifying risk model results
family history details with degree and ages at diagnosis

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; this documentation must be legible, maintained in the record, and made available upon request.

Background, Evidence, and Definitions

Mammography remains the accepted standard for breast cancer screening and diagnosis, but research has investigated additional modalities to address limitations such as reduced sensitivity in dense breast tissue and the need to better distinguish benign from malignant findings.

The policy reviews evidence quality for several newer or adjunctive modalities and lists them as unproven/not medically necessary due to insufficient evidence of efficacy: Computer-Aided Tactile Breast Imaging, Computed Tomography (CT) of the breast, Magnetic Resonance Elastography (MRE), MRI of the breast for individuals who do not meet the defined high-risk criteria, and Molecular Breast Imaging (e.g., Breast Specific Gamma Imaging, scintimammography, Positron Emission Mammography).

Evidence / Source	Key finding
CBBCT sensitivity/specificity (meta-analysis) / Yang et al. 2024
sensitivity 0.92, specificity 0.79 (limited sample sizes)
MRE association with risk / Patel et al. 2022
Stiffness OR=4.26 distinguishing high-risk vs average-risk in dense breasts
Supplemental MRI incremental cancer detection rate / Zeng et al. 2021
Incremental CDR for supplemental MRI 14.2 to 16.5 per 1,000 screens
USPSTF 2024
Evidence insufficient for supplemental screening with breast ultrasonography or MRI after negative mammogram regardless of density
SNMMI/EANM 2022 Practice Guideline
MBI useful in detecting mammographically-occult breast cancer in women with dense breasts and in those at elevated risk who cannot undergo MRI

Term	Definition
Breast Composition Categories
Levels of breast tissue density described by American College of Radiology's Breast Imaging Reporting and Data System. Category A: Almost entirely fatty; Category B: Scattered areas of fibroglandular density; Category C: Heterogeneously dense; Category D: Extremely dense (Sickles et al., 2013)
BSGI/Scintimammography/MBI
Noninvasive diagnostic technology that detects tissues within the breast that accumulate higher levels of a radioactive tracer that emit gamma radiation; performed with a gamma camera after intravenous administration of radioactive tracers (used as adjunct to mammography and physical exam)
Computer-Aided Tactile Breast Imaging
Hand-held tactile array sensor placed in contact with the breast; data signals processed into multi-dimensional color images showing size, shape, hardness, and location of suspicious masses in real time (ACS, 2022)
Magnetic Resonance Elastography (MRE)
Phase-contrast-based MRI technique quantifying mechanical properties (stiffness) of breast tissues; measures elastic modulus differences between normal and malignant tissues using an electromechanical driver and integrated radiofrequency coil unit (ACS, 2022)
Positron Emission Mammography (PEM)
High-resolution metabolic breast imaging using FDG tracer with detectors integrated into a conventional mammography system to acquire emission images immediately after the mammogram (ACS, 2022)
Positron Emission Mammography (PEM) (policy note)
Definition updated in policy (details in definitions section of full policy)

Revision History

2026-04-01Policy updateLatest

Added criterion requiring 'heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) (screening beginning at age 40)' for MRI screening in high-risk individuals. (is_material: true)

2026-04-01Policy updateLatest

Added language indicating screening begins at age 40 for specified family-history-based high-risk criteria. (is_material: true)

2026-04-01Policy update

Policy Summary

PayerUnitedHealthcare

PolicyBreast Imaging for Screening and Diagnosing Cancer (for Nebraska Only)

Policy CodePolicy CS010NE.X

Change TypeRevised MRI coverage criteria; added density requirement

Effective DateApr 1, 2026

Next Review Date

On This Page

screening beginning at age 40*

Personal history of breast cancer (not treated with bilateral mastectomy)

Personal history with specified gene mutations

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

Family history criteria

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

Age Adjustment Rule for Family History

Screening age exception:

ALL of the following

Screening can begin at the listed age or starting 10 years prior to the age of diagnosis of the youngest relative who has been diagnosed with breast cancer (up to third-degree relatives) whichever comes first
but not before age 25

MRI screening excluded when

Not covered when ALL of the following are true:

ALL of the following

Individual does not meet any of the defined high-risk criteria listed in the policy
Policy language revised to state 'MRI of the breast for individuals who do not meet the criteria [listed in the policy]'
MRI requested solely for dense breast tissue without other defined risk factors
Replaced prior language that referenced 'individuals with dense breast tissue not accompanied by defined risk factors'

Documentation should be available upon request

Documentation Required

Document breast composition and risk calculation

Document the patient's breast composition category (heterogeneously dense Category C or extremely dense Category D when applicable) and the risk‑estimate model used and resulting lifetime risk percentage to justify MRI screening coverage.

Gail
Claus
Tyrer-Cuzick
BRCAPRO

Billing Rule

CAD included with MRI breast codes

Computer‑aided detection (CAD) is included with MRI breast CPT codes 77048 and 77049; when CAD is performed with these codes there is no additional reimbursement.

77048
77049

2026-04-01Policy updateLatest

Definitions section updated: Added definition of 'Breast Composition Categories' and updated definition of 'Positron Emission Mammography (PEM)'. (is_material: false)

2026-04-01Policy updateLatest

Updated Clinical Evidence and References sections to reflect current information. (is_material: false)