CurrentUnitedHealthcarePolicy 2026T0375LL

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

UnitedHealthcare Commercial and Individual Exchange medical policy defining medically necessary and not medically necessary breast imaging modalities (MRI, CT, MRE, MBI/BSGI, tactile imaging, scintimammography) with detailed high-risk criteria for MRI screening and summaries of evidence/guideline positions. This part (1 of 2) includes indications, definitions, applicable CPT/HCPCS codes, evidence summaries, and guideline references.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy 2026T0375LL

Change TypeCoverage criteria revised (density added, age rules clarified, unproven list updated)

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders must document family history or model-estimated lifetime risk >=20% and breast density category (heterogeneously or extremely dense) when requesting MRI screening and may need to supply medical records to support coverage.

SourceLink

POLICY UPDATE CHANGES

Revised coverage criteria for MRI of the breast for individuals at high risk for breast cancer, adding requirement for heterogeneously or extremely dense breasts (Category C or D) with screening beginning at age 40.

Updated language to allow screening to begin at listed age or 10 years prior to earliest relative's diagnosis (up to third-degree relatives), whichever comes first, but not before age 25.

Revised list of unproven and not medically necessary services; replaced prior broader wording about MRI for dense breasts 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.

Coverage Summary

This UnitedHealthcare Commercial and Individual Exchange policy (Policy Number 2026T0375LL, effective February 1, 2026) defines which breast imaging modalities are considered medically necessary and which are unproven or not medically necessary. It covers breast MRI (with specific high-risk criteria), computed tomography (breast CT/cone-beam CT), magnetic resonance elastography (MRE), molecular breast imaging/Breast-Specific Gamma Imaging (MBI/BSGI)/scintimammography, computer-aided tactile (tactile array) imaging, and positron emission mammography (PEM).

Medical-Necessity Criteria — MRI of the Breast

MRI of the breast - Proven and medically necessary

Magnetic resonance imaging (MRI) of the breast is proven and medically necessary for individuals who are high risk for breast cancer as defined below.

ANY 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 of 10 and 30 — screening starting at age 25 or 8 years after treatment, whichever is later.

Lifetime risk estimated ≥ 20% as defined by models that are largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick, or BRCAPRO) — screening beginning at age 40*.

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

Personal history with any of the following gene mutations (screening-start notes included):

ATM — screening beginning at age 30*.

BARD1 — screening beginning at age 40*.

BRCA1 or 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-Jeghers syndrome) — screening beginning at age 30*.

TP53 (Li-Fraumeni syndrome) — screening beginning at age 20.

Family history with any of the following:

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 the TP53 or PTEN genes (Li-Fraumeni syndrome, Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, or Peutz-Jeghers 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*.

*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.

Age adjustment rule for family history

Operational rule for adjusting screening start age when family history is present.

Screening can begin at the listed age or starting 10 years prior to the age of diagnosis of the youngest affected relative (considering relatives up to third-degree), whichever comes first; but not before age 25.

Note: The earliest relative used for this calculation may be a first-, second-, or third-degree relative; the rule applies to listed gene carriers and family-history criteria where a listed starting age has an asterisk (*).

MRI screening for individuals at high risk for breast cancer (Revised 02/01/2026)

Revised 02/01/2026. MRI screening for individuals at high risk for breast cancer is covered when ALL of the following are met:

ALL of the following

Individual is asymptomatic and undergoing screening (not diagnostic)
Breast composition is heterogeneously dense (Category C) or extremely dense (Category D), OR the individual meets one or more other high-risk criteria listed below
ONE of
- Prior thoracic radiation therapy between ages 10 and 30 (screening starting at age 25 or 8 years after treatment, whichever is later)
- Lifetime risk ≥ 20% by validated models largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO) (screening beginning at age 40*)

MRI screening for individuals with dense breasts or negative mammogram without defined risk factors

MRI may be considered for screening in individuals with dense breasts or negative mammogram without other defined high-risk factors under the following criteria.

MRI screening for individuals with heterogeneously dense (Category C) or extremely dense (Category D) breasts — considered covered beginning at age 40 as part of the high-risk categories above.

If mammography is negative but dense breast tissue limits mammographic sensitivity, supplemental MRI may be considered when documentation supports decreased sensitivity (e.g., prior false-negative findings or clinical concern) — prior authorization and documentation of rationale may be required.

MRI for screening solely for breast density without additional risk factors should follow the breast composition and age/start rules described in the high-risk criteria; routine MRI for density alone is not indicated before age 40 unless other criteria are met.

Providers should document breast density (BI-RADS category) and any family history, prior radiation, prior breast cancer history, or genetic test results used to support MRI screening.

Not Medically Necessary / Unproven Imaging

Not medically necessary / Unproven

The following imaging modalities/indications 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)
MRI of the breast for individuals who do not meet the MRI high-risk criteria above
Replaced prior language referencing MRI for dense breasts not accompanied by defined risk factors; now explicitly not medically necessary if criteria not met

Coding

Breast MRI (covered when criteria met)CPTCovered

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 CAD, unilateral.
77049	Magnetic resonance imaging, breast, without and with contrast material(s), including CAD, bilateral.

Tactile breast imaging (unproven)CPTExperimental

0422T

Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral.

Breast CT (unproven) / 3D renderingCPTExperimental

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... not requiring image postprocessing on an independent workstation.
76377	3D rendering ... requiring image postprocessing on an independent workstation.

Magnetic resonance elastography / unlisted MRCPTExperimental

76391	Magnetic resonance (e.g., vibration) elastography.
76498	Unlisted magnetic resonance procedure (e.g., diagnostic, interventional).

Scintimammography / Molecular Breast Imaging (MBI) - referenced HCPCSHCPCSExperimental

S8080

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

Computer-aided detection clarificationmixed

note	Computer-aided detection (CAD) is included with MRI breast CPT codes 77048 and 77049; no additional reimbursement if CAD performed with these codes.

Regulated device/product codes referenced (informational)mixed

No codes listed

Provider Actions

Prior Authorization

Prior authorization likely required per plan

Reference the member-specific benefit plan and any applicable federal or state mandates to determine prior authorization requirements. UnitedHealthcare may require prior authorization for imaging studies per the plan terms; confirm plan PA rules before scheduling.

Documentation Required

Medical records documentation may be required

Medical records documentation may be requested to assess whether the member meets the clinical criteria for coverage. Providing documentation to support medical necessity does not guarantee that the service will be covered; benefit plan terms and applicable laws govern final coverage determinations.

Background, Evidence & Definitions

Mammography remains the accepted standard for breast cancer screening and diagnosis, but dense breast tissue reduces mammographic sensitivity. Supplemental imaging modalities (e.g., MRI, ultrasound, contrast-enhanced mammography, MBI/BSGI, CT-based techniques, MRE, tactile imaging) have been investigated to improve detection in dense breasts or other challenging situations. The policy references systematic reviews, meta-analyses, and professional society guidelines evaluating the evidence and tradeoffs (improved cancer detection versus increased recalls/biopsies and variable outcome data).

Evidence / Source	Key finding
CBBCT pooled sensitivity/specificity (Yang et al. 2024)	CBBCT sensitivity 0.92, specificity 0.79; MG sensitivity 0.77, specificity 0.75; AUC CBBCT 0.93, MG 0.83
NC-CBBCT pooled sensitivity/specificity (Uhlig 2019)	NC-CBBCT sensitivity 0.789, specificity 0.697; CE-CBBCT sensitivity 0.899, specificity 0.788
MRE association with risk (Patel 2022)	Stiffness predictive of risk status OR=4.26 (95% CI 1.96-9.25)
Supplemental MRI incremental cancer detection (Zeng 2021)	Incremental CDR for MRI: 14.2–16.5 per 1000 screens; ICR reduced to 0.3–0.8 per 1000 screens in some studies
Scintimammography pooled sensitivity/specificity (meta-analyses)	Sensitivity ~85%, Specificity ~84–86%
USPSTF 2024	Evidence insufficient for supplemental screening with ultrasound or MRI after negative mammogram regardless of breast density

The policy includes concise definitions for key terms and technologies used in breast imaging, including Breast Composition Categories (ACR BI-RADS A–D), Breast-Specific Gamma Imaging (BSGI)/Scintimammography, Computer-Aided Tactile Breast Imaging, Magnetic Resonance Elastography (MRE), Molecular Breast Imaging (MBI), and Positron Emission Mammography (PEM). It also lists applicable CPT/HCPCS codes for these modalities and notes coding/billing clarifications (e.g., CAD included with MRI codes 77048/77049).

Revision History

02/01/2026policy_effectiveLatest

Policy effective date.

02/01/2026revisedLatest

Revised coverage criteria for MRI of the breast for individuals at high risk: added requirement for heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) with screening beginning at age 40; clarified that lifetime risk ≥20% (family-history models) screening begins at age 40; specified several family-history criteria with screening beginning at age 40; updated notated criteria language to indicate screening can begin at the listed age or 10 years prior to the earliest relative's diagnosis (up to third-degree relatives), whichever comes first, but not before age 25; replaced prior wording about MRI for dense breasts alone with 'MRI of the breast for individuals who do not meet the criteria listed in the policy'; updated Definitions (added 'Breast Composition Categories' and updated 'Positron Emission Mammography (PEM)') and updated Clinical Evidence and References sections.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy 2026T0375LL

Change TypeCoverage criteria revised (density added, age rules clarified, unproven list updated)

Effective DateFeb 1, 2026

Next Review Date

SourceLink

On This Page

Known deleterious gene mutation in one of: BRCA1 (screening beginning at age 25), BRCA2 (screening beginning at age 25), TP53 (screening beginning at age 20), ATM (screening beginning at age 30*), BARD1 (screening beginning at age 40*), 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 (screening beginning at age 30*), RAD51C (screening beginning at age 40*), RAD51D (screening beginning at age 40*), STK11 (screening beginning at age 30*)

Family history meeting any of: at least one first-degree relative with BRCA1/BRCA2 mutation (screening beginning at age 40*), first-degree relative with TP53 or PTEN mutation, 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*), or a first- or second-degree male relative diagnosed with breast cancer (screening beginning at age 40*)

Unproven and not medically necessary services (Revised list)

The policy contains a revised list of unproven and not medically necessary breast imaging services (examples listed in supporting sections):

ANY of the following

Breast-specific gamma imaging (BSGI) / Molecular breast imaging (MBI) and scintimammography: considered investigational/unproven or limited; further study needed to determine population and usefulness
Positron Emission Mammography (PEM): definition updated in policy; status listed among definitions/sections
Computed tomography of the breast (cone-beam breast CT): diagnostic accuracy under study
Magnetic resonance elastography (MRE) of the breast: adjunct diagnostic value under investigation
Computer-aided detection for MRI and ultrasound: device information provided; coverage governed by clinical criteria and benefit plan

Documentation Required

Document high-risk criteria for MRI screening

When requesting MRI screening for high-risk individuals, document the specific high-risk elements used to justify coverage per policy criteria.

Family history or model-estimated lifetime risk ≥ 20% (models such as Gail, Claus, Tyrer-Cuzick, BRCAPRO)
Breast density category: heterogeneously dense (Category C) or extremely dense (Category D)
Relevant genetic mutation or family-history details and the screening start age (e.g., BRCA1/BRCA2 start age 25; TP53 start age 20; other listed genes with their noted ages)