ModifiedUnitedHealthcarePolicy CS010KY.06

Breast Imaging for Screening and Diagnosing Cancer (Kentucky)

Coverage criteria for breast imaging modalities used to screen for and diagnose breast cancer in UnitedHealthcare members in Kentucky; defines medically necessary indications, noncovered/unproven modalities, documentation expectations, definitions, and applicable procedure codes.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Imaging for Screening and Diagnosing Cancer (Kentucky)

Policy CodePolicy CS010KY.06

Change TypeRevised clinical criteria and removed CPT codes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionDocument guideline‑based rationale and medical record evidence when ordering supplemental breast imaging to support prior authorization and coverage determination.

SourceLink

POLICY UPDATE CHANGES

Diagnostic breast ultrasound and digital mammography for individuals with dense breast tissue were removed from the list of proven and medically necessary indications.

MRI coverage criteria revised to require heterogeneously or extremely dense breasts (Category C or D) for screening beginning at age 40 and modify age/timing related to prior thoracic radiation.

List of genes associated with recommended MRI screening ages was updated (ATM, BARD1, CDH1, CHEK2, NF1, PALB2, RAD51C, RAD51D added or specified; BRCA1/2, TP53, STK11, PTEN phrasing revised with explicit start ages).

Lifetime risk criteria clarified to include validated models (Gail, Claus, Tyrer‑Cuzick, BRCAPRO) with ≥20% lifetime risk and specified family-history-based indications.

Removed CPT codes 76499, 76641, and 76642 from the applicable codes and supporting information.

>=20%Screening risk threshold

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Coverage Criteria and Clinical Indications

Supplemental Screening Criteria

Supplemental screening modalities (breast MRI, abbreviated MRI, ultrasound, contrast-enhanced mammography, molecular breast imaging) may increase cancer detection but also increase recalls and benign biopsies. Use supplemental screening selectively based on individual risk factors, breast density, and modality availability. The following criteria summarize when supplemental screening is considered medically necessary.

ALL of the following

Breast MRI (including abbreviated MRI) as supplemental screening is considered medically necessary when ANY of the following high-risk or personal-history criteria are met:
ANY of the following
- Personal history of breast cancer (unless treated with bilateral mastectomy).
- Known pathogenic or likely pathogenic genetic mutation associated with increased breast cancer risk (screening start ages noted): BRCA1 or BRCA2 (begin at age 25); TP53 (Li-Fraumeni syndrome) (begin at age 20); ATM (begin at age 30); BARD1 (begin at age 40); CDH1 (begin at age 30); CHEK2 (begin at age 30); NF1 (begin at age 30); PALB2 (begin at age 30); PTEN (Cowden syndrome) (begin at age 30); RAD51C (begin at age 40); RAD51D (begin at age 40); STK11 (Peutz-Jeghers syndrome) (begin at age 30).
- Prior therapeutic or diagnostic chest (thoracic) radiation between ages 10 and 30 (screening beginning at age 25 or 8 years after treatment, whichever is later).
- Calculated lifetime breast cancer risk >= 20% by validated models largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO) (screening beginning at age 40).
- Family history meeting one of the following (screening beginning at age 40 unless otherwise noted): at least one first-degree relative with a 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; first- or second-degree male relative diagnosed with breast cancer (father, brother/half-brother, uncle, grandfather).
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 relatives), whichever comes first, but not before age 25.

Covered Indications by Modality

Breast MRI for screening in high-risk individuals

Breast MRI for screening is covered for individuals at high risk when clinical indications meet the policy criteria:

Indications for screening breast MRI: See medically necessary MRI indications: dense breasts (Category C/D), prior thoracic radiation (age-based), lifetime risk >=20% by specified models, personal history of breast cancer (without bilateral mastectomy), specified pathogenic gene mutations with stated start ages, and family history patterns as listed; family-history-based earlier screening rule (10 years before relative's diagnosis) applies up to third-degree relatives but not before age 25.

Diagnostic workup of screening recalls

Appropriate for diagnostic evaluation of lesions recalled from screening when additional sensitivity or problem-solving information is needed:

Recalled after screening mammography: Contrast-enhanced mammography (CEM) and MRI have high sensitivity for evaluating screen-recalled lesions and may be appropriate for diagnostic workup; DBT and digital mammography have higher specificity for discriminating benign lesions.

Not Covered / Unproven Services

At a policy level, the following are summarized as not covered or excluded due to removal from the applicable codes list or classification as unproven: procedures billed with CPT codes 76499, 76641, and 76642; CT of the breast for screening/diagnosis; computer‑aided tactile breast imaging; magnetic resonance elastography; and molecular breast imaging modalities (BSGI/MBI/scintimammography/PEM). These modalities are listed as unproven, not medically necessary, or are not supported for routine screening in the current policy.

The policy discourages routine screening with molecular imaging (for example, MBI/BSGI/scintimammography/PET) for the general population. ACR practice parameters and guideline reviews highlight insufficient evidence and relatively high radiation dose associated with these techniques, and NCCN/other guidelines do not support routine use for population screening, although they may be considered in select high‑risk patients who cannot undergo MRI.

Procedures that would be billed using the removed CPT codes 76499, 76641, or 76642 are not supported by this policy version. The policy history repeatedly documents removal of these codes from the applicable codes list, and services reported under these codes should not be expected to be covered under this policy.

The ultrasound CPT codes 76641 and 76642 have been removed from the policy's applicable codes listing. As reflected in the revision history, use of these ultrasound codes is no longer supported in this policy segment and billing with these codes may not be accepted.

Removal of CPT codes 76499, 76641, and 76642 appears multiple times across the policy history and supporting information. The practical implication is that claims submitted with these codes may be denied or require correction because they are no longer listed as applicable for breast imaging services under this policy.

Applicable and Removed Codes

Applicable CPT/Category III and related codesmixed

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 CT/MR/US or other tomographic modality with image postprocessing under concurrent supervision; not requiring independent workstation.
76377	3D rendering with interpretation and reporting of CT/MR/US or other tomographic modality with image postprocessing requiring independent workstation.
76391	Magnetic resonance (e.g., vibration) elastography.

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Scintimammography descriptionCPT

76370

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

Removed CPT CodesCPT

76499	Removed from applicable CPT codes
76641	Removed from applicable CPT codes
76642	Removed from applicable CPT codes