ModifiedUnitedHealthcarePolicy CS010KY.06

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

Clinical coverage policy for breast imaging modalities (MRI, CT, molecular imaging, tactile imaging, etc.) applicable to UnitedHealthcare members in Kentucky; governs medical necessity and coding guidance for diagnostic and screening breast imaging procedures.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS010KY.06

Change TypeRevisions to indications, code removals, and documentation requirements

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionProvide complete medical-record documentation supporting medical necessity when requesting supplemental breast imaging; verify and use current applicable CPT codes (removed: 76499, 76641, 76642).

SourceLink

POLICY UPDATE CHANGES

Revised list of proven and medically necessary indications, including removals and changes to MRI criteria and gene-specific screening ages.

Removed diagnostic breast ultrasound and digital mammography for individuals with dense breast tissue from the list of proven and medically necessary indications.

Added specific gene-level screening start ages for multiple genes (e.g., ATM age 30, BRCA1/2 age 25, TP53 age 20).

Replaced MRI criterion for prior thoracic radiation with timing: screening starting at age 25 or 8 years after treatment, whichever is later.

Removed Automated breast ultrasound system, Computer-aided detection (CAD), and Electrical impedance scanning (EIS) from the list of unproven and not medically necessary services.

Added family-history start-age rule allowing screening to begin at the listed age or 10 years prior to the youngest relative's diagnosis (up to third-degree relatives), but not before age 25.

Added medical records documentation language specifying that documentation may be required to assess criteria and must support medical necessity.

Removed CPT codes 76499, 76641, and 76642 from Applicable Codes.

Archived previous policy version CS010KY.05.

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MRI screening threshold by risk models

multipleModalities discussed

1Medical records section added

Coverage Criteria

High-risk MRI screening criteria

MRI of the breast is proven and medically necessary for individuals at high risk when any ONE of the following is present:

High-risk indications for breast MRI: Heterogeneously dense breasts (ACR BI-RADS Category C) or extremely dense breasts (Category D) — screening beginning at age 40.screening beginning at age 40

Density-based indication added to MRI criteria.

High-risk indications for breast MRI: Prior thoracic radiation therapy between ages 10 and 30 — screening starting at age 25 or 8 years after treatment, whichever is later.see text

Timing specified for post‑radiation screening.

High-risk indications for breast MRI: Lifetime risk estimated ≥ 20% by validated, family-history–based models (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO) — screening beginning at age 40.>= 20% lifetime risk

Model-based lifetime risk threshold for MRI screening.

High-risk indications for breast MRI: Personal history of breast cancer (if not treated with bilateral mastectomy).

Personal history indication.

High-risk indications for breast MRI: Personal history of pathogenic or likely pathogenic variants in specified genes with the following screening initiation ages: ATM (begin age 30), BARD1 (begin age 40), BRCA1 or BRCA2 (begin age 25), CDH1 (begin age 30), CHEK2 (begin age 30), NF1 (begin age 30), PALB2 (begin age 30), PTEN (Cowden syndrome) (begin age 30), RAD51C (begin age 40), RAD51D (begin age 40), STK11 (Peutz‑Jeghers syndrome) (begin age 30), TP53 (Li‑Fraumeni syndrome) (begin age 20).age-specified per gene

Gene-specific start ages as listed in policy.

High-risk indications for breast MRI: Family history meeting any of: at least one first‑degree relative with BRCA1 or BRCA2 mutation; first‑degree relative with TP53 or PTEN mutation; at least two first‑degree relatives with breast or ovarian cancer; one first‑degree relative with bilateral breast cancer or both breast and ovarian cancer; or a first‑ or second‑degree male relative (father, brother/half‑brother, uncle, grandfather) diagnosed with breast cancer — screening generally beginning at age 40 (see family‑history age‑start rule for exception).see text

Family history patterns that qualify for MRI screening.

Family history age-start rule

Guidance on starting age when family history is present:

Family-history based age rule: 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 (applies up to third‑degree relatives), whichever comes first, but not before age 25.age rules

Applies to family history–based screening indications (see policy gene and family criteria).

Supplemental screening and diagnostic appropriateness

Covered when consistent with consensus guideline indications and patient risk/density profiles:

High-risk individuals: Supplemental breast MRI (including abbreviated protocols) is appropriate for individuals at high lifetime risk (e.g., genetic mutation carriers, prior chest radiation, lifetime risk ≥20%). If MRI is contraindicated or unavailable, consider contrast‑enhanced mammography (CEM) or molecular breast imaging (MBI); whole‑breast ultrasound may be used when contrast‑enhanced or functional imaging is not available.

Reflects ACR and NCCN guidance; CEM/MBI as alternatives when MRI not feasible.

Extremely dense breasts (EUSOBI recommendation): For women aged 50–70 with extremely dense breasts, consider offering screening breast MRI every 2–4 years with shared decision‑making about benefits and risks.every 2–4 years

Based on EUSOBI recommendation for extremely dense breasts.

Screen‑recalled diagnostic work‑up: In women recalled after screening mammography, contrast‑enhanced mammography (CEM) and MRI demonstrate high sensitivity for detecting malignancy; choice of modality should balance sensitivity and specificity based on diagnostic goals.

Revised Coverage Criteria Summary

Revised proven and medically necessary indications and criteria for breast MRI and other modalities

Supplemental imaging utility: Supplemental screening with breast MRI (with or without contrast), abbreviated MRI, ultrasound, MBI, or CEM can increase cancer detection but may increase recall and benign biopsy rates.

Consistent with NCCN and systematic review findings.

MRI criteria revisions: MRI indications were revised to add density‑based criteria (heterogeneously or extremely dense breasts screening beginning at 40), to specify timing for prior thoracic radiation (screening at age 25 or 8 years after treatment, whichever is later), and to enumerate gene‑specific screening start ages (examples: BRCA1/2 begin age 25; TP53 begin age 20; ATM begin age 30).

See Policy History for full gene list and ages.

Alternate supplemental imaging when MRI unavailable: For high‑risk individuals unable to undergo MRI, consider supplemental screening with CEM or MBI; whole‑breast ultrasound may be used if contrast‑enhanced or functional imaging is not available or accessible.

NCCN recommendation.

Screening initiation for persons with family history

Screening initiation timing when family history is present

Family-history screening initiation: Screening may begin at the listed age OR start 10 years prior to the age at diagnosis of the youngest affected relative (applies up to third‑degree relatives), whichever comes first, but not before age 25.age rule

Clarifies family‑history start‑age exception; examples of relatives expanded (includes half‑brother).

This policy focuses on supplemental and diagnostic breast imaging beyond routine preventive screening mammography. It does not address routine preventive breast cancer screening performed with conventional mammography (see note). Indications for breast MRI are defined separately in the policy and apply only when the individual meets the listed high‑risk criteria (for example, genetic mutation carriers, prior chest radiation, or model‑based lifetime risk thresholds).

The policy does not support routine population screening with molecular imaging modalities (for example, BSGI/MBI, scintimammography, or positron emission mammography). Available evidence is limited, concerns about radiation exposure are noted, and professional guidance does not endorse these modalities for routine screening.

Automated breast ultrasound system (ABUS), computer‑aided detection (CAD), and electrical impedance scanning (EIS) were removed from the policy’s list of supported indications and definitions as part of the revision history updates.

Historically, Automated Breast Ultrasound System (ABUS), Computer‑Aided Detection (CAD), and Electrical Impedance Scanning (EIS) were identified in prior policy text as unproven and not medically necessary due to insufficient evidence of efficacy; these items were addressed in the policy prior to their removal from the unproven list.

CPT codes 76499, 76641, and 76642 have been removed from this policy and are no longer listed as applicable procedure codes in the current policy version.

The referenced chunks are policy history and revision entries; they contain archival and supporting‑information updates but do not introduce standalone coverage criteria in the excerpt provided.

Supporting information and policy history indicate removal of CPT codes 76499, 76641, and 76642 from the policy’s code listings and supporting documentation.

Policy revision entries note that CPT codes 76499, 76641, and 76642 were removed from the policy’s applicable codes list and therefore are not recognized for coverage under this revision.

Multiple policy history entries repeatedly reference the removal of CPT codes 76499, 76641, and 76642 as part of the Applicable Codes updates in the revision history.

Additional revision history records reiterate the removal of CPT codes 76499, 76641, and 76642, reflecting the same change across multiple policy history entries.

The provided policy history excerpts are administrative and archival in nature and do not contain new coverage criteria or explicit exclusions within the excerpted text.

These policy history chunks contain summary and archival information only; they do not add new coverage exclusions or change coverage stance within the excerpt shown.

Within the available excerpt there are no explicit coverage exclusions introduced beyond the documented removals of specific technologies and CPT codes noted elsewhere in the revision history.

This segment of the document is policy history and does not present explicit coverage exclusions; it primarily records changes to applicable codes and supporting information.

Modalities discussed in the policy include tactile imaging, computed tomography of the breast (including cone‑beam breast CT), magnetic resonance elastography (MRE), and magnetic resonance imaging (MRI). The policy scope covers use of these modalities for supplemental and diagnostic breast imaging in members evaluated for elevated risk, diagnostic work‑up, or when MRI is contraindicated/unavailable.

Guidance in the policy aligns with external recommendations that annual MRI screening is not recommended for women with <15% lifetime risk (ACS) and acknowledges limited evidence supporting routine use of molecular imaging modalities for population screening; MRI and other supplemental modalities are targeted to individuals with defined risk profiles.

The USPSTF has concluded that current evidence is insufficient to determine the balance of benefits and harms for routine supplemental screening with ultrasound or MRI after a negative screening mammogram, irrespective of breast density.

MRI performed for individuals who do not meet the policy’s listed criteria (the high‑risk indications enumerated elsewhere in the policy) is considered not covered under the MRI‑specific criteria in this policy.

No explicit 'Not Medically Necessary' statements are present in the supplied policy history excerpt beyond the previously documented categorizations of specific modalities as unproven or removed; the history entries mostly record code and definition updates.

Within the provided policy history segments there are no additional explicit 'not medically necessary' statements; most content documents administrative changes to applicable codes and supporting information.

See the CODING section for the full list of applicable CPT and professional procedure codes and descriptions; the policy’s Applicable Codes table contains the authoritative code set for billing and coverage determinations.

Covered Indications and Use

Breast MRI for screening in high-risk individuals

Breast MRI for screening is covered for high‑risk individuals when ALL of the following top‑level condition is met:

Breast MRI for screening in high-risk individuals: Request is for screening MRI of the breast in an asymptomatic individual and ANY one of the high‑risk indications (genetic mutation per policy, family history patterns, prior chest radiation, lifetime risk ≥20%, personal history of breast cancer without bilateral mastectomy, or dense breasts meeting Category C/D criteria) is present.see detailed criteria

Medical records documenting risk assessment or genetic test results may be required to support coverage.

Modality-specific diagnostic and supplemental screening indications

Modality‑specific diagnostic and supplemental screening indications:

CE‑CBBCT (cone beam breast CT): Contrast‑enhanced CBBCT may offer higher diagnostic sensitivity and specificity than non‑contrast CBBCT and can be considered for diagnostic evaluation, recognizing evidence is limited and protocols vary.

Coding and Applicable Procedure Codes

Applicable CPT/Professional Procedure CodesCPT

0422T	Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral.
0633T	Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material.
0634T	Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s).
0635T	Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s).
0636T	Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s).
0637T	Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s).
0638T	Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s).
76376	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing; not requiring image postprocessing on an independent workstation.
76377	3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing requiring an independent workstation.
76391	Magnetic resonance (e.g., vibration) elastography.

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Removed/Updated Applicable CPT CodesCPT

76499	Removed CPT code
76641	Removed CPT code
76642	Removed CPT code