CurrentUnitedHealthcarePolicy CSRADOOZOH.D

Breast Imaging Guidelines (For Ohio Only)

UnitedHealthcare Community Plan clinical guideline for breast imaging applicable only to members in the state of Ohio, providing evidence-based recommendations, general imaging modality guidance (US, CT, MRI, PET), coding and billing guidance, and requirements for medical necessity determinations effective November 1, 2025.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRADOOZOH.D

Change TypeClarified Ohio applicability; periodic evidence updates

Effective DateNov 1, 2025

Next Review Date

Key ActionProvide clinical presentation, recent history and physical exam since onset/change in symptoms, pertinent labs and prior imaging to establish medical necessity.

POLICY UPDATE CHANGES

Policy applies only to the state of Ohio and effective date is November 1, 2025.

Annual evidence-based updates performed on 02/01/2024, 07/01/2024 (interim), and 05/01/2025.

V1.0.2025Guideline version

93Document pages (partial doc total)

listedHigh-risk screening categories

severalInvestigational codes

Alternative imaging generally

Coverage Summary

UnitedHealthcare Community Plan Breast Imaging Guidelines (Ohio only) effective November 1, 2025 provide evidence-based, state-specific guidance for appropriate advanced breast imaging and related procedures. The guideline takes a mixed coverage stance — supporting imaging when clinically indicated (based on personal/family history, physical exam, and symptoms) while limiting or not supporting routine/alternative modalities where evidence is insufficient. Primary goals include promoting appropriate use of advanced imaging, clarifying coding and billing expectations, and ensuring medical necessity determinations follow documented history/physical exam and Ohio Administrative Code requirements.

Key thresholds and quick facts

MRI BI-RADS 3 follow-upRepeat MRI at 6 months; if remains BI-RADS 3 then repeat at 12, 18, and 24 months; after 2 years of stability reclassify as BI-RADS 2 (benign)

Mammogram/US BI-RADS 3 follow-upRepeat the original study at 6 months; if still BI-RADS 3 repeat at 12, 18, and 24 months; after 2 years of stability classify as BI-RADS 2 (benign)

High‑risk MRI: Li‑Fraumeni (TP53)Start annual MRI at age 20

High‑risk MRI: BRCA1/BRCA2Start annual MRI at age 25

High‑risk MRI: STK11, PTEN, CDH1, NF1, PALB2, ATM, CHEK2Start annual MRI at age 30

High‑risk MRI: BARD1, RAD51C, RAD51DStart annual MRI at age 40

High‑risk lesions (ADH/ALH/LCIS)Start MRI at time of diagnosis but not before age 25

Prior chest radiationStart MRI at age 25 OR 8 years after completion of radiation therapy, whichever is later

Implant imaging — routine surveillance timingNo routine advanced imaging if <5 years after implant placement; initial imaging at >5 years with follow-up every 2–3 years after an initial negative study

Implant imaging — suspected rupture: salineIf exam equivocal: <30 yrs → ultrasound; 30–39 or ≥40 yrs → ultrasound or diagnostic mammogram; if indeterminate then breast MRI without contrast (CPT 77047)

Implant imaging — suspected rupture: siliconeAll ages: if asymptomatic and <5 yrs → no routine imaging; initial imaging at >5 yrs → ultrasound (MRI without contrast CPT 77047 if ultrasound indeterminate); if exam equivocal → ultrasound OR MRI without contrast (CPT 77047)

Medical-Necessity Criteria and Clinical Requirements

Application / Medical Necessity Determination

Determination for breast imaging is made case-by-case considering clinical history, exam, and Ohio rules.

Policy applies only to the state of Ohio

Requests for unproven services or those with coverage/age/time/quantity limits will be evaluated using Ohio Administrative Code 5160-1-01

Clinical Documentation Requirements

Adequate clinical information is required to establish medical necessity, including but not limited to:

Clinical presentation (not just the study requested)

Recent detailed history and physical exam since onset or change in symptoms (face-to-face or other meaningful contact may suffice)

Coding and Billing Reference

Breast biopsy guidance and biopsy codes (covered)CPTCovered

19085	Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen; first lesion, including MR guidance
19086	Biopsy, breast... each additional lesion, including MR guidance

Imaging guidance codes referenced (covered)CPTCovered

75989	Imaging guidance for percutaneous drainage with placement of catheter (all modalities)
76942	Ultrasonic guidance for needle placement
77011	CT guidance for stereotactic localization
77012	CT guidance for needle placement
77013	CT guidance for, and monitoring of parenchymal tissue ablation
77021	MR guidance for needle placement
77022	MR guidance for, and monitoring of parenchymal tissue ablation

3D rendering and post-processing codes (covered)CPTCovered

76376	3D rendering not requiring image post-processing on an independent workstation
76377	3D rendering requiring image post-processing on an independent workstation

Unlisted procedure codes (covered)CPTCovered

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional)
78999	Unlisted procedure, diagnostic nuclear medicine

SPECT/CT and PET coding references (neutral)CPT

78830	Hybrid Nuclear/CT single area single day
78831	Hybrid Nuclear/CT 2 or more days
78832	Hybrid Nuclear/CT 2 areas with mixed days
78072	SPECT/CT parathyroid nuclear imaging (effective Jan 1, 2013)

Limited or follow-up CT (covered)CPTCovered

76380

Limited or follow-up CT scan

3D rendering/billing exclusion pairings (not_covered)CPTNot Covered

76376/76377

Should not be billed in conjunction with CAD, MRA, CTA, nuclear medicine SPECT, PET, PET-CT, Mammogram, MRI Breast, US Breast, CT Colonography, Cardiac MRI/CT, or Coronary CTA

Supported/Referenced CPT Codes (covered)CPTCovered

76380	Limited or follow-up CT (limited CT protocol)
78072	SPECT/CT parathyroid nuclear imaging
78830	Hybrid nuclear/CT scan single area single day
78831	Hybrid nuclear/CT scan 2 or more days
78832	Hybrid nuclear/CT scan 2 areas with one day and 2-day study
76140	Interpretation of an outside study
0648T	Quantitative mpMRI analysis (single organ) - Category III
0649T	Quantitative mpMRI analysis with diagnostic MRI - Category III
0697T	Quantitative mpMRI analysis (multiple organs) - Category III
0698T	Quantitative mpMRI analysis with diagnostic MRI (multiple organs) - Category III

1–10 of 29

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Investigational / Not Medically Necessary CPT Codes (experimental)CPTExperimental

0648T	Quantitative mpMRI analysis (without diagnostic MRI) - considered investigational/experimental
0649T	Quantitative mpMRI analysis (with diagnostic MRI) - considered investigational/experimental
0697T	Quantitative mpMRI analysis (multiple organs) - investigational
0698T	Quantitative mpMRI with diagnostic MRI - investigational
0865T	Volumetric/quantitative brain MRI analysis - not medically necessary
0866T	Volumetric/quantitative brain MRI analysis - not medically necessary
C8937	HCPCS CAD MRI algorithm analysis - considered investigational/experimental

HCPCS / Other Codes referenced (neutral)mixed

C8908	HCPCS MRI Breast Bilateral, with and without contrast
C8931	Example HCPCS (MRA with dye, Spinal Canal) referenced as similar to CPT 72159
S8042	Non-specific HCPCS MRI code (low field) - redirect to specific CPT code

Supported/Referenced CPT (covered)CPTCovered

76641	Breast ultrasound, unilateral, complete (diagnostic)
76642	Breast ultrasound, unilateral, limited
77047	Breast MRI without contrast (document references 'CPTC 77047')
77049	Breast MRI without and with contrast (document references CPT 77049 for lactating women)
78800	Molecular Breast Imaging (MBI)
76376	3D rendering; not to be used with 3D mammography or MRI Breast
76377	3D rendering, additional; not to be used with 3D mammography or MRI Breast
0634T	CT Breast (document lists CPTC 0634T)
0638T	CT Breast (document lists CPTC 0638T)

Alternative/Not supported imaging techniques (not_covered)mixedNot Covered

78811

PET mammography / PEM (document references PEM often billed as CPT 78811); not supported for routine screening/diagnosis

Key billing rules: guidance procedure codes (e.g., 19085 for first MRI‑guided breast biopsy and 19086 for each additional lesion) include the imaging component so do not bill 77021 for breast biopsy. Only one unit of a guidance code (e.g., 77012/77021/76942) should be reported per encounter/date of service. CPT 76376/76377 have supervision and exclusion rules and should not be billed with breast MRI or many other listed studies. CPT 76380 is limited to true limited/follow‑up CT work and not for treatment planning or to cover extra slices. When PET‑MRI is allowed, report as 78813 + 76498. Whole‑body MRI must be reported using 76498.

Provider Actions, Prior Authorization and Documentation

Documentation Required

Submit adequate clinical information for medical necessity

Provide clinical presentation (not just requested study), recent detailed history and physical exam since onset or change in symptoms, pertinent labs and prior imaging to establish medical necessity. For pediatric patients (≤18) follow Pediatric Imaging Guidelines; adults follow General Imaging Guidelines. Face-to-face evaluation may be required in some scenarios; telehealth/other meaningful contact (telephone, video, email) since onset/change can substitute when allowed.

Pediatric guideline note: ≤18 follow Pediatric Imaging Guidelines (else follow General Imaging Guidelines).
Telehealth accepted as meaningful contact substitute for face-to-face evaluation when applicable.

Billing Rule

Billing for MR-guided breast biopsy

Use CPT 19085 for the first MRI‑guided breast biopsy site and CPT 19086 for each additional concurrent lesion. Do NOT report CPT 77021 for breast biopsy; 19085/19086 include imaging and needle placement for MR‑guided breast biopsy.

Background and Evidence

Background: this is an evidence‑based proprietary UnitedHealthcare clinical guideline developed using national society guidance (e.g., ACR, NCCN), peer‑reviewed literature, and applicable regulatory references. Medical necessity determinations reference the Ohio Administrative Code (OAC 5160‑1‑01) and the policy is explicitly applicable only to the state of Ohio.

Label	Value
Sources cited
ACR practice parameters, FDA GBCA guidance, peer-reviewed literature and selected references (document references ACR, NCCN, American Cancer Society and multiple journal articles)
Incidental lesions frequency
Incidental lesions seen on 15% of breast MRI studies; percentage of incidental lesions malignant ranges from 3% to 20%; MRI identifies cancer in 0.7% of inconclusive mammographic lesions.
Sensitivity of contrast-enhanced MRI
Contrast-enhanced MRI sensitivity for invasive cancers and benign papillary lesions reported at 93–100%.
Radiation exposure PEM vs digital mammography
Positron emission mammography (PEM) radiation exposure ~23 times higher than digital mammography.

Definitions

Concurrent supervision: active physician participation and monitoring of the 3D reconstruction process including selection of anatomic region, tissue types/structures to display, images to archive, and real‑time adjustment of the 3D work product.

WBMRI: whole‑body MRI; generally not supported except for select cancer predisposition syndromes or specific conditions; report using unlisted MR code 76498 due to lack of established CPT/HCPCS codes.

SPECT/CT: Single Photon Emission Computed Tomography combined with CT for localization, attenuation correction, and improved anatomic localization.

CAD: computer‑aided detection for MRI breast; CAD is included with CPT 77049/77048 and HCPCS C8937 is considered investigational/unnecessary.

Pathologic nipple discharge: unilateral, bloody or serous, arising from a single duct, persistent, and spontaneous.

Physiologic nipple discharge: predominantly bilateral, often milky, multi‑duct, and may be associated with endocrine causes.

Revision History

02/01/2024interim_update

Annual evidence-based updates performed (summary of changes notes an annual evidence-based update on this date).

07/01/2024interim_update

Interim evidence-based updates and minor editorial updates performed (document lists this interim update date).

05/01/2025interim_update

Annual evidence-based updates performed (summary of changes lists this date).

Policy Summary

PayerUnitedHealthcare

PolicyBreast Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRADOOZOH.D

Change TypeClarified Ohio applicability; periodic evidence updates

Effective DateNov 1, 2025

Next Review Date

Key ActionProvide clinical presentation, recent history and physical exam since onset/change in symptoms, pertinent labs and prior imaging to establish medical necessity.

On This Page

Pertinent laboratory and prior imaging studies as applicable

Pediatric (≤18) follow Pediatric Imaging Guidelines; >18 follow General Imaging Guidelines unless otherwise specified

General Modality Considerations and Appropriateness

Guidance on modality selection and when advanced imaging is appropriate:

Prefer standard/conventional imaging (mammogram, ultrasound, CT, MRI) for initial and subsequent evaluations

Use advanced imaging when initial imaging is inconclusive/indeterminate and the result will affect management

Do not substitute MRI solely to avoid ionizing radiation if MRI is not supported by condition-specific guidance

PET is not indicated for surveillance imaging unless specified in condition-specific guidelines

Contrast Use and Contraindications

Considerations and cautions for CT and MRI contrast use:

Appropriate contrast level is condition-specific per guideline sections

CT contrast cautions: CT contrast use requires caution in renal impairment; CT without contrast may be appropriate for elevated BUN/creatinine, renal insufficiency, allergies, diabetes, thyroid disease treated with I-131, very elderly, urgent/trauma settings

MRI gadolinium cautions: Gadolinium contrast is contraindicated in pregnancy unless benefit outweighs risk; caution in renal failure due to NSF risk; limit repetitive GBCA use because of deposition concerns

FDA recommends limiting GBCA use to circumstances where additional information is necessary

Overutilization Precautions

Precautions to minimize unnecessary or duplicative imaging:

Review prior imaging to avoid duplicate studies

Obtain results of initial diagnostic tests before further advanced imaging

Imaging should be expected to impact clinical management or treatment decisions

Repeat imaging only for evidence of progression/recurrence or when repeat study will affect management

Avoid CT double-contrast (without and with) except for limited indications

3D Rendering and Post-Processing Codes (CPT 76376/76377)

Use, supervision, exclusions, and clinical scenarios for CPT 76376/76377:

General supervision and billing: Concurrent physician supervision/active participation is required for CPT 76376/76377; 76376 for non-independent workstation; 76377 requires independent workstation; do not bill 3D rendering for 2D reformatting and do not bill with CTA/MRA/CAD/Mammogram/MRI Breast/US Breast/PET/PET-CT and other listed studies

Clinical scenarios where 76376/76377 may be considered: Congenital skull abnormalities for pre-op planning in newborns/infants/toddlers; spine fractures, pelvic/acetabular fractures, intra-articular and complex fractures for pre-op planning when conventional imaging insufficient; complex facial fractures; cerebral angiography; selected pelvic/abdominal scenarios when ultrasound equivocal (e.g., lost IUD, uterine intracavitary lesion)

Guidance for CT/MR/US-Guided Procedures and Billing

Guidance on imaging guidance procedure coding and single-unit reporting:

Guidance procedure codes include the imaging necessary to guide needle/catheter; do not routinely bill diagnostic procedure codes in conjunction with guidance codes

Guidance codes examples: Report guidance with specified CPT codes (e.g., 19085/19086 for MR-guided breast biopsy; 76942 ultrasound guidance; 77011 stereotactic CT localization; 77012 CT guidance for needle placement; 77013 CT ablation guidance; 77021 MR guidance for needle placement; 77022 MR ablation monitoring; 75989 drainage with catheter)

Breast biopsy coding: Use CPT 19085 for first MR-guided breast biopsy lesion and CPT 19086 for each additional lesion; CPT 77021 is not appropriate for breast biopsy

Unitization: Only one unit of guidance codes (e.g., 77012/77021/76942/77002/77003) should be reported per individual encounter/date of service

Unlisted Procedure Codes

When to use unlisted procedure codes and preference for Category III when available:

Use CPT 76497 (unlisted CT), 76498 (unlisted MR), or 78999 (unlisted nuclear medicine) when no appropriate anatomic site-specific code exists

Report a Category III code instead of an unlisted code if an appropriate Category III descriptor exists

Examples include custom joint arthroplasty planning, neurosurgical navigation/planning, or procedures requiring different acquisition parameters

Limited CT (CPT 76380) Guidance

Use and limitations for CPT 76380 (limited or follow-up CT):

CPT 76380 describes a limited or follow-up CT scan when the work of a full diagnostic code is not performed

Common examples include limited slices for known pulmonary nodule, limited sinus CT, limited slices for non-healing fracture; 76380 is not indicated for treatment planning

Do not report CPT 76380 in conjunction with other diagnostic CT codes to cover extra slices; coding must reflect actual limited work performed

SPECT/CT Imaging

SPECT/CT modality use and reporting codes:

SPECT/CT combines SPECT nuclear imaging and CT for localization, accuracy, and attenuation correction

Common studies include 123/131-MIBG and octreotide scintigraphy; CPT 78072 effective Jan 1, 2013 for SPECT/CT parathyroid imaging

Hybrid nuclear/CT scans reportable as CPT 78830 (single area/single day), 78831 (2+ days), or 78832 (2 areas with mixed days)

Interpretation of Outside Studies (CPT 76140)

Interpretation of externally performed studies:

Do NOT use diagnostic imaging codes to interpret an exam performed at another facility; use CPT 76140 for secondary interpretation of outside images

If the outside exam is used for comparison with a current exam, the current diagnostic code includes comparison to the prior study

Quantitative MR Analysis (Category III codes)

Coverage stance for quantitative multiparametric MRI and volumetric analyses:

Category III CPT codes for quantitative mpMRI analysis (e.g., 0648T, 0649T, 0697T, 0698T) are considered investigational/experimental for coverage purposes

Volumetric/quantitative MRI brain analysis codes (0865T, 0866T) are considered not medically necessary for routine clinical practice

Whole-Body CT and Whole-Body MRI

Whole-body CT and whole-body MRI appropriateness and coding:

Whole-Body CT: Whole-body CT (LifeScan) screening of asymptomatic individuals is NOT indicated; whole-body low-dose CT supported for oncologic staging in Multiple Myeloma

Whole-Body MRI: Whole-body MRI is generally NOT supported except for select cancer predisposition syndromes and some autoimmune conditions; no established CPT/HCPCS codes exist for WBMRI and WBMRI should be reported using CPT 76498 when appropriate

PET‑MRI

PET‑MRI limited support and required coding when allowed:

PET‑MRI is generally not supported for most oncologic/neurologic conditions but may be appropriate in select circumstances when PET‑CT criteria are met and PET‑CT is unavailable or provider requests PET‑MRI

When PET‑MRI is appropriate, report using PET Whole-Body (CPT 78813) plus MRI Unlisted (CPT 76498); other reporting methods are inappropriate; diagnostic MRI codes may be reported concurrently when clinically appropriate

General Breast Imaging Principles

General principles for breast imaging and MRI coding:

A current clinical evaluation since onset/change in symptoms is usually required prior to advanced breast imaging; other meaningful contact may substitute; clinical evaluation not required for screening

When MRI Breast indicated, any ONE of CPT 77049 (bilateral with and without contrast), HCPCS C8908 (bilateral with and without contrast), or CPT 77047 (bilateral without contrast) is supported; unilateral MRI breast is NOT clinically supported

If implants present and MRI requested to assess implant integrity (and imaging otherwise indicated), CPT 77047 (MRI breast without contrast) is supported

Breast Ultrasound Indications

When breast ultrasound is appropriate and follow-up expectations:

Routine breast ultrasound as standalone screening or with screening mammography is NOT indicated; it is an alternative supplemental screening for high-risk females with dense breasts when MRI cannot be performed

Supplemental screening for high-risk with dense breasts: If MRI not performed in past year for high-risk screening, bilateral breast ultrasound for supplemental screening in high-risk females with dense breasts is supported

BI-RADS ultrasound follow-up: BI-RADS category 3 ultrasound follow-up: repeat at 6 months; if remains category 3 then repeat at 12, 18, 24 months; after 2 years stability reclassify as benign (category 2)6 months/12/18/24 months

No office visit necessary prior to breast ultrasound when an abnormality identified on mammogram; axilla ultrasound CPT 76882 and US-guided biopsy CPT 19083 include imaging component

MRI Breast Coding and Related Rules

MRI breast coding, contrast, CAD, and investigational code guidance:

Gadolinium contrast is required for evaluation of breast parenchyma

CAD is included with CPT 77049/77048; HCPCS C8937 is considered investigational and not necessary

Gadolinium is not necessary for evaluation of implant integrity in asymptomatic, average-risk individuals (use 77047)

MRI-guided breast biopsy billing: CPT 19085 includes imaging and needle placement; do NOT bill CPT 77021 for breast biopsy; additional lesions billed with CPT 19086

Do not bill CPT 76376/76377 in conjunction with MRI Breast since CAD software performs 3D imaging

MRI Breast Indications and Follow-up (including BI-RADS guidance)

Indications for MRI breast and follow-up/BI-RADS recommendations:

Equivocal/occult mammogram or US findings: MRI is indicated when radiologist recommends MRI to assess inconclusive/conflicting mammography or ultrasound findings (including inconclusive fat necrosis without discrete palpable mass); documented histopathologic discordance between core-needle biopsy and imaging—MRI supported prior to surgical management

Limits on MRI use: MRI is NOT indicated to determine biopsy recommendations for lesions that can be readily biopsied (palpable masses, microcalcifications); BI-RADS 3 lesions on mammogram/US are NOT considered equivocal for MRI and should follow mammogram/US surveillance schedule; BI-RADS 4 or 5 lesions should be biopsied—MRI should not replace biopsy

MRI BI-RADS 3 follow-up: MRI BI-RADS 3 lesions: repeat MRI in 6 months; if remains BI-RADS 3 then repeat at 12, 18, 24 months; after 2 years stability classify as benign6 months/12/18/24 months

Post-biopsy imaging: If lesion was initially seen on MRI and histology benign/non-specific, MRI can be repeated at least 6 months after biopsy to document sampling success>=6 months

Risk-based Annual MRI Breast Screening Criteria

Risk-based annual MRI breast screening criteria with start ages and thresholds:

Annual MRI screening indicated for individuals meeting listed high-risk criteria

Genetic mutation start ages: Start ages: Li-Fraumeni (TP53) = 20; BRCA1/2 = 25; STK11, PTEN, CDH1, NF1, PALB2, ATM, CHEK2 = 30; BARD1, RAD51C, RAD51D = 40; ADH/ALH/LCIS = at diagnosis but not before age 25

Chest radiation: Personal history of chest radiation before age 30: start at 25 or 8 years after completion of radiation therapy, whichever is laterstart age = 25 or 8 years post-radiation

Not indicated groups: Mutations/variants with <15% absolute risk (MSH2, MLH1, MSH6, PMS2, EPCAM, NBN, VUS, intermediate penetrance) - additional MRI screening NOT indicated<15% absolute risk

Breast Implant Evaluation

Breast implant evaluation pathways and timing for saline vs silicone implants:

Routine surveillance imaging for asymptomatic individuals to assess implant integrity (silicone or saline) is NOT supported

Saline implant pathway: If exam equivocal for rupture: <30 years -> ultrasound initial; 30-39 or ≥40 -> ultrasound or diagnostic mammogram initial; if ultrasound/diagnogram indeterminate, MRI without contrast (CPT 77047) is supported; asymptomatic -> no routine imaging

Silicone implant pathway: Asymptomatic <5 years after placement: no routine advanced imaging; asymptomatic initial imaging >5 years with follow-up every 2-3 years after initial negative imaging using ultrasound (MRI without contrast CPT 77047 if ultrasound indeterminate); if exam equivocal -> ultrasound OR MRI without contrast (CPT 77047)>5 years then q2-3 years

Saline ruptures often clinically apparent; silicone rupture less apparent—use combination of ultrasound, mammogram, and/or MRI when exam equivocal; MRI not indicated for capsular contracture

Breast Reconstruction Preoperative Imaging

Preoperative imaging recommendations for flap donor and recipient vessel evaluation:

CTA or MRA of the donor body part (e.g., abdomen/pelvis) can be performed for preoperative planning for free-tissue transfer flaps (e.g., DIEP) using appropriate CTA/MRA abdomen/pelvis codes

Routine use of CTA chest (CPT 71275) to evaluate recipient vessels is NOT indicated except when prior cardiac/vascular surgery or known vascular anomalies

Insufficient evidence to support routine advanced imaging for pedicled flaps (e.g., TRAM); routine preop imaging not supported

Breast Implant Evaluation

Modality selection for implant evaluation based on implant type, age, and symptoms:

For saline implants: asymptomatic individuals do not need MRI; if exam equivocal use ultrasound (<30) or ultrasound/diagnostic mammogram (≥30); if indeterminate, MRI without contrast CPT 77047

For silicone implants: if exam equivocal, use ultrasound and/or mammogram and/or MRI without contrast (CPT 77047); routine advanced imaging not supported if <5 years after placement; initial imaging at >5 years with follow-up every 2-3 years after initial negative imaging>5 years then q2-3 years

If biopsy is discordant with imaging, MRI for further evaluation is supported

Evaluation of Suspicious Imaging or Palpable Mass

Approach when suspicious imaging findings or palpable mass are present:

Initial evaluation involves biopsy (percutaneous or surgical if percutaneous not feasible); lesions BI-RADS 4 or 5 require biopsy

If biopsy results are discordant with imaging findings, MRI for further evaluation is supported prior to surgical management

MRI is NOT indicated to replace biopsy for suspicious lesions

BI-RADS 3 imaging requires short-term follow-up at 6, 12, and 24 months per guideline6/12/24 months

Nipple Discharge / Galactorrhea (BR-6.1)

Evaluation pathway for nipple discharge distinguishing physiologic from pathologic:

Initial imaging includes diagnostic mammogram and targeted ultrasound (CPT 76641 or 76642); if these are negative or inconclusive, breast MRI is the next appropriate study

Physiologic nipple discharge pathway: If discharge is physiologic with no suspicious exam findings and mammogram and ultrasound negative, no additional imaging necessary and reassure patient

Pathologic nipple discharge pathway: Pathologic discharge (unilateral, bloody/serous, single duct, persistent) should follow imaging and biopsy pathway as indicated; if initial imaging negative/inconclusive proceed to MRI

Breast Pain (Mastodynia) (BR-7.1)

Imaging recommendations for breast pain:

Mammogram and ultrasound are the initial imaging studies for breast pain (CPT 76641 or 76642)

Evaluation requires history and physical exam

Advanced imaging (MRI) is NOT routinely indicated for breast pain when mammogram and ultrasound are negative

If mammogram or ultrasound are not negative, follow MRI Breast Indications guidance

Alternative Breast Imaging Approaches (MBI, PEM, CT Breast, Others) (BR-8.1)

Stance on alternative and emerging breast imaging modalities:

Molecular Breast Imaging (CPT 78800) is supported for individuals who meet MRI screening criteria but cannot undergo MRI

Other alternative techniques (BSGI, scintimammography, PEM, impedance mammography, thermography, CT breast CPT 0634T/0638T, cone beam CT) are usually not appropriate and are not supported for routine screening or diagnosis

Radiation risk note: PEM has substantially higher radiation exposure (reported ~23x digital mammography); CT breast and PEM remain under investigation

Suspected Breast Cancer in Males (BR-9.1)

Evaluation strategy for suspected breast cancer in males:

Limited evidence for MRI use in male breast disease; follow breast ultrasound guidance as applicable

Presentation with suspicious findings usually requires mammography and ultrasound followed by core needle biopsy if studies are BI-RADS 4-5

For male gynecomastia without suspicious features, clinical management/reassurance is appropriate

Breast Evaluation in Pregnant or Lactating Females (BR-10.1)

Imaging approach during pregnancy and lactation:

Breast ultrasound (CPT 76641 or 76642) is first-line imaging in pregnant and lactating patients

If pregnant/lactating patient has palpable mass or persistent unilateral bloody nipple discharge and ultrasound is negative or suspicious, follow with diagnostic mammogram with abdominal lead shielding

Breast MRI with gadolinium (CPT 77049) is supported for lactating women if criteria met; IV gadolinium is contraindicated in pregnancy; biopsy is recommended rather than advanced imaging when mammogram and ultrasound are inconclusive in pregnancy

3D Rendering (BR-13.1)

Billing and use restrictions for 3D rendering in breast imaging:

3D rendering (CPT 76376/76377) should NOT be billed in conjunction with any 3D mammography code

3D rendering (CPT 76376/76377) should NOT be used in conjunction with MRI Breast

3D rendering (CPT 76376/76377) is NOT indicated for breast ultrasound (including ABUS)

Affected codes: 19085, 19086, 77021

Billing Rule

Guidance codes unitization

Only one unit of imaging-guidance codes should be reported per individual encounter/date of service. Guidance codes include CT, MR, ultrasound and fluoroscopy guidance codes; report a single unit per encounter regardless of number of lesions or localizations.

Affected codes: 77012, 77021, 76942, 77002, 77003

Documentation Required

Physician supervision for 3D rendering

When reporting CPT 76376 or CPT 76377, document active physician participation and concurrent supervision per ACR recommendations. Documentation should reflect the physician’s role in design of the anatomic region, tissue types/structures to display, images archived, and real-time monitoring/adjustment of the 3D reconstruction.

Billing Rule

3D rendering exclusions

Do not bill CPT 76376 or CPT 76377 in conjunction with CTA, MRA, CAD, mammography, MRI breast, breast ultrasound, PET, PET‑CT, SPECT, or other listed studies — 2D reformats and CAD are included in cross‑sectional base codes and are not separately reimbursable.

Excluded pairings: CTA, MRA, CAD, Mammogram, MRI Breast, US Breast, PET, PET-CT

Billing Rule

Unlisted code use

Use unlisted procedure codes when no anatomic-specific CPT exists: CPT 76497 for unlisted CT, CPT 76498 for unlisted MRI, and CPT 78999 for unlisted diagnostic nuclear medicine. If an appropriate Category III code exists that describes the procedure, report the Category III code instead of an unlisted code.

Affected codes: 76497, 76498, 78999

Documentation Required

Clinical evaluation requirement

Obtain and document a current clinical evaluation (relevant history and physical exam, appropriate labs and non‑advanced imaging such as mammogram/ultrasound) since onset or change in symptoms prior to ordering advanced breast imaging. If face‑to‑face is not performed, document alternative meaningful contact (telephone, video, email). Note: a current clinical evaluation is not required for screening studies.

Billing Rule

Coding for PET‑MRI

When PET‑MRI is used in lieu of PET‑CT (and criteria met), report the study using PET Whole‑Body CPT 78813 plus MRI unlisted CPT 76498. Other methods of reporting PET‑MRI are inappropriate. Diagnostic MRI codes may also be reported when clinically appropriate.

Affected codes: 78813, 76498

Billing Rule

CPT 76380 use limits

Limit CPT 76380 to studies where only limited or follow‑up CT work was performed. Do not use CPT 76380 for treatment planning or to represent extra slices when a full diagnostic CT code is warranted; coding must reflect the actual limited work performed.

Affected code: 76380

Billing Rule

MRI‑guided biopsy billing

For MRI‑guided breast biopsy billing, CPT 19085 includes the imaging component and needle placement for the first lesion and CPT 19086 for additional lesions. Do NOT bill CPT 77021 for MR guidance for needle placement in breast biopsy.

Affected codes: 19085, 77021

Prior Authorization

Whole‑body MRI reporting

When whole‑body MRI is indicated, report using the unlisted MR procedure CPT 76498. Other methods of reporting whole‑body MRI are inappropriate; WBMRI lacks established discrete CPT codes.

Affected code: 76498

Documentation Required

Breast implant imaging pathway

For breast implant evaluation follow the age- and implant‑type‑specific pathway: saline implants — ultrasound initial if <30, ultrasound or diagnostic mammogram if ≥30; silicone implants — ultrasound and/or mammogram with MRI without contrast (CPT 77047) if ultrasound indeterminate. Document implant type, age, exam findings, and prior imaging.

Affected codes referenced: 77047, 76882

Documentation Required

Use age-appropriate mammography vs ultrasound

Document patient age to determine initial imaging for nipple discharge or implant evaluation. Use ultrasound (CPT 76641/76642) in younger patients (<30) as first imaging; diagnostic mammogram is typically used for older patients per guideline age thresholds.

Affected codes: 76641, 76642

Prior Authorization

MRI after discordant biopsy or negative/indeterminate initial imaging

When ordering MRI after a discordant biopsy or after negative/indeterminate initial mammogram and/or ultrasound, verify and obtain any required prior authorization per plan rules before proceeding. MRI is supported for further evaluation when biopsy and imaging are discordant or when initial imaging is negative/inconclusive per guideline criteria.

Affected codes: 77047, 77049

Billing Rule

3D rendering billing restrictions

Do not report CPT 76376 or CPT 76377 in conjunction with 3D mammography codes, MRI Breast, or breast ultrasound procedures; 3D rendering is not indicated or reimbursable with these breast imaging modalities.

Affected codes: 76376, 76377

Denial Risk

Alternative techniques not supported

Claims for alternative breast imaging techniques (commonly billed as listed codes) such as PEM, dedicated CT breast, and some nuclear techniques are usually not appropriate and may be denied. Use caution and support with guideline‑specified indications if claiming these modalities.

Affected codes: 78811, 0634T, 0638T, 78800

2025-11-01policy_effectiveLatest

Policy effective date established for Ohio-only Breast Imaging Guidelines (Document labeled V1.0.2025; applies only to the state of Ohio).