UnitedHealthcare breast MRI Coverage Update | OpenPayer
ModifiedUnitedHealthcarePolicy CS010NM.D
Breast Imaging for Screening and Diagnosing Cancer (New Mexico)
Medical policy governing coverage and medical necessity criteria for breast imaging modalities (particularly breast MRI and several novel imaging techniques) for UnitedHealthcare members in New Mexico.
Policy Summary
PayerUnitedHealthcare
PolicyBreast Imaging for Screening and Diagnosing Cancer (New Mexico)
Policy CodePolicy CS010NM.D
Change TypeRevised coverage criteriaadded density- and age-based MRI rules
Effective DateApr 1, 2026
Next Review Date
Key ActionObtain and document clinical risk, breast density, and age/start criteria when requesting prior authorization for breast MRI to support medical necessity.
Revised coverage criteria for magnetic resonance imaging of the breast for individuals who are high risk for breast cancer, adding breast density and clarifying age/start rules.
Added criterion requiring heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) for certain MRI screening beginning at age 40.
Added language that screening can begin at 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.
Revised list of unproven and not medically necessary services; replaced MRI-not-covered wording about 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)'.
>=20%Lifetime risk threshold referenced
Age 40Density-based MRI start age
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Not before 25
Minimum earlier start age
3Unproven technologies listed
04/01/2026Effective date
Coverage Criteria for Breast Imaging
Breast MRI: Medically necessary indications
Breast MRI is proven and medically necessary when ANY of the following high-risk indications are present (screening ages indicated):
High-risk breast MRI indications: Includes individuals with: heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) (screening beginning at age 40); prior thoracic radiation therapy between ages 10 and 30 (screening starting at age 25 or 8 years after treatment, whichever is later); lifetime risk estimated >= 20% by family-history–based models (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO) (screening beginning at age 40 or per family-history age rules); personal history of breast cancer without bilateral mastectomy; personal history with specific gene mutations with listed start ages (TP53 from age 20; BRCA1/BRCA2 from age 25; ATM, CDH1, CHEK2, NF1, PALB2, PTEN, STK11 from ~age 30; BARD1, RAD51C, RAD51D from ~age 40 as noted); qualifying family history patterns (e.g., at least one first-degree relative with BRCA1/2 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; first- or second-degree male relative with breast cancer) (screening beginning at age 40 unless earlier start is indicated by family-history timing).see age-start rules in text
Screening may begin 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; exact gene-specific start ages are specified in source text.
Magnetic resonance imaging (MRI) screening — high risk
Covered when ALL of the following are met
High-risk MRI criteria: Individual meets high-risk definitions such as: lifetime risk >= 20% by family-history–based models, qualifying family-history patterns (e.g., first-degree relative with BRCA1/2 mutation, two first-degree relatives with breast/ovarian cancer, one first-degree relative with bilateral breast cancer or both breast and ovarian cancer, or male first- or second-degree relative with breast cancer), or other listed high-risk personal/genetic criteria.lifetime risk >= 20%
Breast density or alternative justification: Individual has heterogeneously dense (Category C) or extremely dense (Category D) breasts OR another qualifying high-risk indication justifies MRI; if MRI cannot be performed, consider CEM or MBI; whole-breast ultrasound may be used when contrast-enhanced or functional imaging is not available.Category C or D
EUSOBI recommends MRI screening every 2–4 years for extremely dense women aged 50–70; supplemental modalities increase detection but may increase recalls/biopsies.
Supplemental and diagnostic imaging coverage considerations
Covered when aligned with guideline-defined risk or density scenarios (per ACR/NCCN/EUSOBI recommendations):
High-risk MRI screening: Annual breast MRI (with or without contrast) is usually appropriate for women at high risk (e.g., BRCA mutation carriers, prior chest irradiation, lifetime risk >=20%); MRI may be added to or substitute for mammography per guideline age thresholds.per guideline criteria
ACR and NCCN support MRI in high-risk individuals; mutation carriers and those with lifetime risk >=20% are typical candidates.
Alternatives when MRI contraindicated or unavailable: For high-risk individuals who cannot undergo MRI, consider contrast-enhanced mammography (CEM) or Molecular Breast Imaging (MBI); whole-breast ultrasound may be used if contrast-enhanced or functional imaging is not available or accessible.MRI contraindication or inaccessibility
NCCN and ACR guidance recommend CEM/MBI/ultrasound as alternatives in select patients.
Unproven / Not medically necessary
Explicit non-covered services: Computer-Aided Tactile Breast Imaging; CT of the breast; Magnetic Resonance Elastography (MRE); MRI of the breast for individuals who do not meet the policy's listed high-risk criteria; Molecular Breast Imaging (e.g., BSGI, scintimammography, Positron Emission Mammography).
These services are listed as unproven or not medically necessary due to insufficient evidence and/or higher radiation exposure.
Indications and evidence summaries by modality
Contrast-enhanced cone-beam CT (CE-CBBCT): CE-CBBCT may be considered for diagnostic evaluation; pooled studies report higher sensitivity and specificity for CE-CBBCT versus non-contrast CBBCT, with CE-CBBCT sensitivity ~0.899 and specificity ~0.788; evidence is limited and further validation is needed.diagnostic context; investigational status persists
Diagnostic accuracy may be numerically comparable to breast MRI in some meta-analyses; protocols varied across studies.
Magnetic Resonance Elastography (MRE): MRE is investigational for routine diagnostic decision-making; studies indicate tissue stiffness correlates with risk in dense breasts but require further validation before routine use.investigational
Prospective studies demonstrate association of stiffness measures with risk status but clinical utility remains unproven.
Molecular Breast Imaging / BSGI / Scintimammography: Molecular imaging techniques may have utility as adjunctive diagnostic tools but are not supported for routine population screening due to limited outcome evidence and higher radiation exposure.
Supplemental screening for high-risk individuals and those with dense breasts
Supplemental screening indications: Supplemental screening (MRI, abbreviated MRI, ultrasound, MBI, CEM) can increase cancer detection in high-risk individuals or those with dense breasts; MRI is the preferred supplemental modality for high-risk patients, with CEM, MBI, or whole-breast ultrasound as alternatives when MRI is not possible.
Guideline organizations (ACR, NCCN, EUSOBI, SBI/SNMMI) support tailored supplemental screening based on risk and density; benefits must be weighed against increased recalls and biopsies.
This policy addresses advanced breast imaging modalities and supplemental screening beyond routine preventive mammography. Routine screening with conventional mammography is not addressed by this policy. Several modalities are explicitly considered unproven or not medically necessary for screening or in individuals who do not meet the policy's specified high-risk criteria; see the Not Covered section for details.
Molecular breast imaging techniques such as breast-specific gamma imaging (BSGI) and scintimammography have limited and methodologically heterogeneous evidence. Studies report moderate-to-high sensitivity and specificity but do not demonstrate improved clinical outcomes when used as a routine adjunct to mammography. In addition, professional guidance and practice parameters note a relatively higher radiation burden with these techniques and recommend against their routine use for population screening.
The policy revision clarifies that MRI of the breast performed for individuals who do not meet the policy's specified high-risk and breast-composition criteria is now listed among services considered unproven or not medically necessary. Requests for breast MRI should therefore document that the member meets the stated risk, age, and density criteria to avoid potential denial.
The policy lists several specific novel or investigational breast imaging modalities as unproven or not medically necessary, including Computer-Aided Tactile Breast Imaging, Computed Tomography (CT) of the breast (including cone-beam CT variants), and Magnetic Resonance Elastography (MRE). Evidence for these technologies is limited by small, uncontrolled studies and methodological concerns, and their impact on clinical outcomes has not been established.
The American Cancer Society (ACS) guidance states that newer technologies (for example scintimammography, positron emission techniques, and electrical impedance imaging) have received FDA approval as diagnostic adjuncts but have not undergone sufficient clinical testing to justify use for routine screening. The ACS specifically recommends against annual MRI screening for women at average risk (lifetime risk less than 15%).
Current evidence does not support the routine use of molecular imaging modalities (e.g., BSGI, scintimammography, PEM) as population screening tools. Meta-analyses and guideline statements note limited outcome data and caution that these tests deliver a substantially higher whole-body effective radiation dose than mammography, so they are not recommended for general screening.
Applicable Procedure Codes and Coding Notes
Applicable procedure codesCPT | HCPCS | mixed
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 under concurrent supervision; 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 under concurrent supervision; requiring image postprocessing on an independent workstation.
76391
Magnetic resonance (e.g., vibration) elastography.
RuleScreening may begin at the age listed for the qualifying criterion or 10 years prior to the age of diagnosis of the youngest affected relative (up to third-degree), whichever comes first.
LimitationThis relative-based early start is not permitted to result in beginning screening before age 25.
Degree of relatives consideredApplies to relatives up to the third degree (e.g., first-, second-, and third-degree relatives).
ExamplesIf the youngest relative was diagnosed at 35 and the listed start age is 40, screening may begin at age 25 (10 years before 35) but not before 25 per policy rule.
Lifetime risk threshold used to determine eligibility for MRI screening
Provider Requirements and Prior Authorization
Prior Authorization
Prior authorization and coverage determination
Coverage determinations and prior authorization are subject to member benefit, medical necessity, and any applicable federal, state, or contractual requirements. Verify the member's benefit plan and any state or contractual mandates before requesting authorization.
Check federal, state, and contractual benefit plan requirements before requesting coverage or authorization.
Reference applicable benefit language when breast MRI, CEM, or MBI is requested for screening outside routine guidelines.
Prior Authorization
Authorization for supplemental screening
Prior authorization is likely required for supplemental screening modalities (breast MRI, contrast-enhanced mammography [CEM], molecular breast imaging [MBI]) when used for screening in higher-risk patients or when used outside routine indications. Requests should include documentation demonstrating the indication and how the request meets policy criteria.
Include clinical indication, relevant risk assessment, and breast density in the request.
Definitions
Breast Composition Categories — ACR BI-RADS
Category AAlmost entirely fatty.
Category BScattered areas of fibroglandular density.
Category CHeterogeneously dense.
Category DExtremely dense.
Breast Composition Categories — policy definition
Definition sourceBreast Composition Categories defined per American College of Radiology (BI-RADS) and added to policy definitions.
Clinical relevancePolicy requires Category C (heterogeneously dense) or Category D (extremely dense) breasts as qualifying density-based indication for MRI screening beginning at age 40.
Contrast Use and Safety Considerations
Billing Rule
CE-CBBCT diagnostic performance vs NC-CBBCT
Contrast-enhanced cone-beam breast CT (CE-CBBCT) demonstrated higher pooled sensitivity (0.899) and specificity (0.788) than non-contrast CBBCT in pooled studies; consider this diagnostic performance and study heterogeneity when selecting modalities and documenting rationale.
Billing Rule
Contrast use — benefits and risks
Use of intravenous iodinated or gadolinium contrast improves detection for CE modalities (CE-CBBCT, CEM, MRI) but carries risks of contrast reactions; document contraindications and rationale when ordering contrast-enhanced exams.
Billing Rule
CEM considerations — increased detection vs contrast risk
Services Considered Not Medically Necessary / Not Covered
Computer-Aided Tactile Breast Imaging; CT of the breast (including cone-beam techniques); Magnetic Resonance Elastography (MRE); and MRI of the breast for individuals who do not meet the policy's specified high-risk criteria are listed as not covered. These modalities are considered unproven or not medically necessary due to insufficient evidence of benefit.
Molecular Breast Imaging (MBI) / Breast-Specific Gamma Imaging (BSGI) used for routine population screening is not covered. The ACR practice parameters and systematic reviews cite insufficient evidence for screening use and raise concerns about the relatively high radiation dose associated with BSGI/MBI.
Routine molecular imaging modalities (MBI/BSGI/PEM) are considered not medically necessary for general screening because available studies do not establish improved outcomes and these techniques are associated with a higher radiation exposure compared with mammography. The policy revision also explicitly lists MRI performed when the individual does not meet the policy criteria among not medically necessary services.
Unproven / Not medically necessary
Explicit non-covered / not medically necessary items:
Unproven and not medically necessary modalities: 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 criteria listed in this policy; Molecular Breast Imaging (e.g., Breast-Specific Gamma Imaging, scintimammography, Positron Emission Mammography).
Frequency and Timing
Breast MRI (screening) frequency guidance
Frequency guidanceEUSOBI recommends offering screening breast MRI every 2–4 years in women aged 50–70 years with extremely dense breasts; policy frequency limit cites every 2–4 years for this group.
Policy contextPolicy notes supplemental MRI increases cancer detection but also may increase recalls and benign biopsies; modality availability and individual preferences should be considered.
ApplicabilityFrequency guidance applies specifically to extremely dense breasts per EUSOBI; other high-risk indications (e.g., BRCA carriers) follow guideline-specified annual MRI recommendations.
Relative start age with minimum age constraint
Primary ruleScreening may begin at the listed criterion start age or 10 years prior to the age at diagnosis of the youngest affected relative (up to third-degree), whichever comes first.
Policy Summary
PayerUnitedHealthcare
PolicyBreast Imaging for Screening and Diagnosing Cancer (New Mexico)
Policy CodePolicy CS010NM.D
Change TypeRevised coverage criteriaadded density- and age-based MRI rules
Effective DateApr 1, 2026
Next Review Date
Key ActionObtain and document clinical risk, breast density, and age/start criteria when requesting prior authorization for breast MRI to support medical necessity.
Age/start timing: Screening begins at age 40 for density-based indications; for family-history–based criteria, screening may begin 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.not before age 25
Policy revision (effective 04/01/2026) clarifies age/start timing and family-history rules.
Adjunct imaging for diagnostic work-up of recalled lesions:
For patients recalled from screening mammography, CEM, MRI, digital breast tomosynthesis (DBT), and ultrasound demonstrate high sensitivity for diagnostic work-up; choice depends on modality availability and lesion characteristics.
diagnostic recall context
Systematic reviews show supplemental MRI yields higher incremental cancer detection rates; increased recall and biopsy rates should be considered.
diagnostic adjunct only
Meta-analyses show moderate-high sensitivity and specificity, but routine screening is not recommended by guideline bodies.
Supplemental MRI/CEM/Ultrasound: Use supplemental MRI, abbreviated MRI, CEM, or ultrasound for selected high-risk or dense-breast patients per guideline recommendations; these approaches increase cancer detection but also recall and biopsy rates.per guideline-defined risk/density
ACR, NCCN, EUSOBI guidance summarized; choice depends on patient risk, density, and modality availability.
Threshold
>= 20% lifetime risk as estimated by family-history–based models (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO).
ApplicationUsed to determine eligibility for screening breast MRI when calculated lifetime risk meets or exceeds the threshold.
Age/start guidanceFor lifetime-risk–based indication, screening begins at age 40 per revised policy language.
If MRI is being requested as the supplemental modality of choice per guideline-based high-risk recommendations, document inability to undergo MRI if an alternative (CEM or MBI) is requested.
Prior Authorization
Prior authorization for breast MRI
Requests for breast MRI must meet the policy's specified high-risk and density criteria; prior authorization should follow the policy coverage criteria and include supporting documentation.
Provide risk assessment results (e.g., lifetime risk score from Gail, Claus, Tyrer‑Cuzick, BRCAPRO) when applicable.
Document specific qualifying family-history details (e.g., first‑degree relative with BRCA1/BRCA2 mutation, two first‑degree relatives with breast/ovarian cancer, male relative with breast cancer).
Documentation Required
Medical record documentation
The patient's medical record must fully support the medical necessity for the requested services. Lack of adequate documentation may result in denial or non‑coverage.
Include relevant medical history, physical exam findings, and results of prior diagnostic tests or imaging.
Maintain legible documentation in the medical record and make it available upon request.
Documentation Required
Document risk and density
When ordering supplemental imaging, providers should document the patient's breast density and calculated risk status in the record and on the authorization request.
Record breast composition category (e.g., heterogeneously dense — Category C; extremely dense — Category D).
Include lifetime risk estimate and the risk model used, or specific family-history details if applicable.
Denial Risk
MBI/scintimammography screening denial risk
Use of molecular breast imaging (MBI) or other molecular imaging modalities for routine screening is not supported by current evidence and may be denied.
MBI/scintimammography for screening is considered unproven and may result in denial.
If requesting MBI, provide justification and cite inability to use guideline-preferred modalities when applicable.
Denial Risk
Coverage conditional on meeting MRI criteria
Coverage is conditional on meeting the policy's MRI criteria; requests for MRI when the individual does not meet defined high‑risk and density criteria are at risk of denial.
If the member does not meet the listed high‑risk and density criteria, do not assume MRI will be approved.
Document any extenuating clinical circumstances and reference benefit plan requirements when seeking exception.
Risk impactBreast density is an independent risk factor and reduces mammography sensitivity; EUSOBI recommends MRI every 2–4 years in women 50–70 with extremely dense breasts.
Molecular Breast Imaging (MBI) / BSGI / Scintimammography
DefinitionMolecular Breast Imaging (MBI) / Breast-Specific Gamma Imaging (BSGI) / scintimammography: functional nuclear medicine imaging that uses an injected radioactive tracer and a gamma camera to detect areas of increased tracer uptake in the breast.
Typical useProposed primarily as an adjunct to mammography and physical exam to help select patients for biopsy or further diagnostic evaluation.
Evidence limitationsAvailable studies have methodological limitations and lack evidence demonstrating improved outcomes when used as routine adjunctive screening.
MBI / Scintimammography — nuclear medicine techniques and radiation note
TechniqueNuclear medicine techniques (e.g., Tc-99m sestamibi, BSGI) that detect metabolic activity in breast tissue by intravenous radiotracer administration and gamma camera imaging.
Radiation noteThese techniques involve a higher radiation burden than mammography and their routine use for population screening is not supported by current evidence.
Policy stanceMBI/BSGI/scintimammography may be considered as an adjunctive diagnostic tool but are listed as unproven and not medically necessary for routine screening due to limited outcome data.
Magnetic Resonance Elastography (MRE) — definition
DefinitionMagnetic Resonance Elastography (MRE) of the breast: a phase-contrast MRI technique that measures mechanical properties (elastic modulus) of tissues to quantify stiffness and elasticity.
MechanismApplies a known stressor and measures resulting tissue deformation to distinguish stiffer malignant tissue from normal fibroglandular tissue.
Clinical statusFeasibility demonstrated but clinical benefits and diagnostic applications remain under evaluation; further research needed before routine use.
Magnetic Resonance Elastography (MRE) — investigational note
Investigational statusMRE is considered investigational for diagnostic decision-making beyond demonstrating relative stiffness differences; clinical utility requires further validation.
Quantitative outputProvides quantitative depiction of tissue stiffness and elasticity which may help stratify lesions, but no current definitive diagnostic thresholds established.
EquipmentPerformed using an electromechanical driver and integrated radiofrequency coil unit in an MRI suite by a trained radiologist.
Computer-Aided Tactile Breast Imaging — definition
DefinitionComputer-Aided Tactile Breast Imaging: hand-held tactile array sensor is moved across the breast; data are processed into multi-dimensional color images to show size, shape, hardness, and location of suspicious masses in real time.
Intended useProposed to assist clinicians in detecting palpable masses and characterizing tissue hardness as an adjunct to physical exam.
Policy statusListed among modalities considered unproven and not medically necessary for routine breast screening or diagnostic replacement per policy.
Cone Beam Breast CT (CBBCT) — definition and pooled accuracy
DefinitionCone Beam Breast CT (CBBCT): dedicated breast CT available in non-contrast (NC-CBBCT) and contrast-enhanced (CE-CBBCT) forms for diagnostic breast imaging.
Pooled accuracyMeta-analysis: CE-CBBCT pooled sensitivity 0.899 and specificity 0.788; NC-CBBCT pooled sensitivity 0.789 and specificity 0.697; CE-CBBCT diagnostic accuracy was numerically comparable to breast MRI in pooled studies.
Evidence noteAvailable studies are limited and heterogeneous; further validation needed before widespread clinical adoption for screening.
DefinitionPositron Emission Mammography (PEM): high-resolution metabolic imaging for breast cancer using an FDG tracer with detectors integrated into a mammography system to acquire emission images immediately after mammography.
Policy updatePEM definition was updated in the policy's definitions section (see revision history).
UseConsidered among molecular imaging techniques; routine screening use is not supported by current evidence per policy.
Contrast-enhanced mammography (CEM) increases cancer detection compared with mammography alone but carries the risk of iodinated contrast reactions; consider CEM when MRI is not possible and document the rationale and any contrast precautions.
Listed as unproven or not medically necessary due to insufficient evidence of efficacy and/or higher radiation exposure.
Minimum age floor
Screening start based on relative's age cannot be earlier than age 25.
Example applicationFor family-history scenarios with listed start ages (commonly age 40), apply the 10-years-prior rule but ensure not to start before age 25.