RetiredUnitedHealthcarePolicy CS010LA.V

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

State-specific (Louisiana) UnitedHealthcare Community Plan medical policy governing coverage and medical necessity for breast imaging modalities (mammography, MRI, CT, ultrasound, and novel/adjunct technologies) for screening and diagnosis of breast cancer.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS010LA.V

Change TypeRetirement and code/coverage revisions

Effective DateFebruary 1, 2026 - March 31, 2026

Next Review DateN/A

Key ActionCheck federal, state, or contractual requirements and ensure medical records fully document medical necessity as claims for Louisiana membership are affected by policy retirement on Apr. 1, 2026.

SourceLink

POLICY UPDATE CHANGES

Revised list of unproven and not medically necessary indications; removed automated breast ultrasound system, computer-aided detection (CAD), and electrical impedance scanning (EIS).

Removed language indicating diagnostic breast ultrasound and digital mammography for individuals with dense breast tissue are proven and medically necessary.

Removed CPT codes 76499, 76641, and 76642 from applicable codes.

Policy retired for Louisiana plan membership disenrolled on Apr. 1, 2026.

Added instructions clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria.

Louisiana-onlypolicy application

1/yearallowed frequency

annual (high-risk)

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severalnot medically necessary

04/01/2026retirement date

Coverage criteria and modality determinations

State-Specific Criteria — Screening Mammography

Screening mammography is allowed once per calendar year when ANY of the following criteria are met:

Screening mammography eligibility: Any woman age 30 or older with hereditary susceptibility from pathogenic mutation carrier status or prior chest wall radiation; OR provider recommendation for any woman 35 years of age or older with a predicted lifetime risk greater than 20 percent; OR any woman 35 through 39 (one baseline mammogram allowable if not meeting other criteria); OR any woman 40 years of age or older.1 per calendar year

Providers should perform the most clinically appropriate method (film or digital).

State-Specific Criteria — MRI

Breast MRI may be reimbursed annually for qualifying indications when ANY of the following are met:

MRI eligibility: Women at least 25 years of age with hereditary susceptibility from pathogenic mutation carrier status or prior chest wall radiation; OR provider recommendation for any woman 35 years of age or older with a predicted lifetime risk greater than 20 percent; OR any woman 40 or older with increased breast density (C or D) if recommended by their physician; OR women with a prior history of breast cancer below 50 years of age; OR women with a prior history of breast cancer at any age and dense breasts (C or D density).annual

A breast ultrasound is the initial preferred modality, followed by MRI if ultrasound is inconclusive in the instance of prior history plus density.

Not Medically Necessary / Unproven Modalities

The following modalities are considered unproven and not medically necessary due to insufficient evidence:

Unproven/Not Medically Necessary: Computer-Aided Tactile Breast Imaging; Computed tomography (CT) of the breast; Magnetic Resonance Elastography (MRE); Molecular Breast Imaging (e.g., Breast Specific Gamma Imaging, scintimammography, Positron Emission Mammography).

Refer to Breast Imaging Guidelines section for 3D rendering of breast ultrasound, breast MRI, or CT of the breast.

Modalities: Evidence and guideline-based stance

Coverage considerations and evidence statements by modality

Cone-beam breast CT (CBBCT): Systematic review of cone-beam breast CT (CBBCT) shows contrast-enhanced CBBCT (CE-CBBCT) has higher pooled sensitivity and specificity than non-contrast CBBCT (NC-CBBCT); CE-CBBCT diagnostic accuracy is numerically comparable to breast MRI but larger prospective studies and longer follow-up are needed before broader adoption.

Uhlig 2019: CE-CBBCT pooled sensitivity 0.899 and specificity 0.788; NC-CBBCT pooled sensitivity 0.789 and specificity 0.697.

Magnetic Resonance Elastography (MRE): Feasibility and small prospective studies indicate MRE can quantify breast tissue stiffness and may improve diagnostic performance when combined with contrast-enhanced MRI; however, larger studies are required to validate clinical utility and determine appropriate patient selection.

Patel 2022 reports stiffness associated with elevated risk (OR 4.26) in dense breasts; Siegmann 2010 found adding MRE to MRI increased diagnostic accuracy in a small study.

Molecular Breast Imaging / BSGI / Scintimammography: MBI and BSGI demonstrate relatively high sensitivity and specificity in diagnostic studies and meta-analyses and may detect mammographically-occult cancers in dense breasts, but evidence is limited by study design, potential bias, and concerns about higher radiation dose; there is insufficient evidence that these modalities improve screening outcomes over alternatives.

Guideline and evidence context

Policy scope and stance referenced through guideline citations and policy changes

Guideline statements: SNMMI procedure standards and practice guidelines note MBI/BSGI may detect mammographically-occult cancers in women with dense breasts but recommend further study; USPSTF finds evidence insufficient to determine benefits and harms of supplemental ultrasound or MRI after a negative mammogram; NCCN and ACR provide conditional recommendations for CEM, MBI or ultrasound when MRI is not feasible.

Policy history: retired for Louisiana plan membership on 04/01/2026 and revisions removed certain technologies and updated medical record/coverage instructions.

Codes labeled with an asterisk (*) are not on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana Medicaid Program. Providers should verify the LA Medicaid fee schedule before submitting claims, as specific procedure codes and modalities that carry an asterisk in the coding tables will not be reimbursed by the State program.

The American College of Radiology (ACR) practice parameter notes insufficient evidence to support routine use of Breast-Specific Gamma Imaging (BSGI) / Molecular Breast Imaging (MBI) and, because of the relatively high radiation dose associated with these techniques, recommends against their use for screening. This guideline position should be considered when evaluating coverage of BSGI/MBI for population screening.

This policy was retired for Louisiana plan membership, effective April 1, 2026. As part of the revision history, language was removed from the lists indicating certain procedures were "proven and medically necessary," and several technologies were removed from the lists of covered or referenced items. Providers should reference the policy history for details on removed items and the retirement effective date.

The policy identifies several modalities as unproven and not medically necessary due to insufficient evidence, including Computer-Aided Tactile Breast Imaging, Computed Tomography (CT) of the breast, Magnetic Resonance Elastography (MRE), and Molecular Breast Imaging (e.g., BSGI, scintimammography, Positron Emission Mammography). These modalities are listed to support not medically necessary determinations where applicable.

The National Comprehensive Cancer Network (NCCN) states that current evidence does not support routine use of molecular imaging (for example, BSGI, sestamibi scan, or PEM) as screening procedures. While NCCN acknowledges emerging data for detection in women with dense breasts, it highlights that these tests carry a substantially higher whole-body effective radiation dose than mammography and therefore are not supported for routine population screening.

Changes made in the recent revision include a revised list of unproven and not medically necessary indications and the removal of specific technologies from lists (for example, automated breast ultrasound system, computer-aided detection [CAD], and electrical impedance scanning [EIS]). The revision history also documents removal of language that labeled diagnostic breast ultrasound and digital mammography for individuals with dense breasts as proven and medically necessary, and the removal of CPT codes 76499, 76641, and 76642 from the applicable code lists.

Indications where imaging is covered

Screening and diagnostic use of mammography and MRI per state-specific criteria

Mammography indications: See state-specific screening mammography criteria allowing one screening mammogram per calendar year for age- and risk-based indications (age 30+ with hereditary susceptibility or prior chest wall radiation; provider-recommended for age ≥35 with lifetime risk >20%; single baseline for 35–39; or any woman ≥40).1 per calendar year

Providers should perform the most clinically appropriate method (film or digital).

MRI indications: See state-specific MRI eligibility criteria allowing annual MRI for qualifying indications (women ≥25 with hereditary susceptibility or prior chest wall radiation; provider-recommended for age ≥35 with lifetime risk >20%; age ≥40 with dense breasts if recommended; prior history of breast cancer <50 years; or prior history at any age with dense breasts).annual

Breast ultrasound is initial preferred modality followed by MRI if ultrasound is inconclusive in certain instances.

Procedure codes and frequency limits

Prior Authorization

Coding & prior authorization note

Coding Clarification: Computer-aided detection (CAD) is included with the MRI breast CPT codes 77048 and 77049. If CAD is performed with these codes, there is no additional reimbursement.

CAD is included with MRI breast CPT codes 77048 and 77049; no separate reimbursement for CAD.

Documentation Required

Procedure documentation and medical records

Providers should document procedure details and safety measures in the medical record: indication for the study, imaging modality used, laterality, contrast administration (if applicable), findings, comparison studies, and any immediate post-procedure care or complications. Procedure documentation must support medical necessity and may be requested for review.

Document indication, modality, laterality, contrast use, findings, comparisons, and post-procedure care

Provider responsibilities, prior authorization, and documentation

Note

Check federal/state/contractual requirements and third‑party tools

Before applying this policy, verify federal, state, or contractual requirements for benefit coverage; UnitedHealthcare may use third-party tools (for example, InterQual) to assist in administering benefits.

Step Therapy

Sequence imaging in prior cancer with dense breasts: ultrasound first, then MRI if inconclusive

For patients with a prior history of breast cancer who also have dense breasts (C or D), perform breast ultrasound first; if ultrasound is inconclusive, follow with breast MRI as indicated by the policy.

Documentation Required

Maintain complete medical records to support reviews

Ensure the patient’s medical record contains relevant history, physical exam, and results of pertinent diagnostic tests or procedures to support medical necessity; these records may be requested for review.

Prior authorization considerations

Billing Rule

Confirm CPT codes against state fee schedule for coverage

Some MRI and advanced breast imaging CPT/T codes listed in the policy may not be on the Louisiana Medicaid Fee Schedule and therefore may not be covered—refer to the coding clarification and state fee schedule when submitting claims.

Examples of listed MRI CPT codes: 77046, 77047, 77048, 77049.

Prior Authorization

Prior authorization likely needed for MBI/BSGI used as screening

Prior authorization may be expected for MBI/BSGI when used for screening or supplemental screening because professional societies caution against routine screening use and note higher radiation exposure.

Contrast administration and protocol notes

Billing Rule

CE‑CBBCT showed superior pooled diagnostic performance vs NC‑CBBCT

Contrast-enhanced cone‑beam breast CT (CE‑CBBCT) protocols varied across studies; CE‑CBBCT demonstrated higher pooled sensitivity and specificity compared with non‑contrast CBBCT in the reviewed evidence.

Billing Rule

IV contrast protocols varied; CE‑CBBCT generally had better diagnostic performance

Protocols for iodinated IV contrast administration in CE‑CBBCT differed across studies; CE‑CBBCT generally showed better diagnostic performance than NC‑CBBCT and may affect contrast administration and billing considerations.

Terms and modality definitions

BSGI definition — Breast Specific Gamma Imaging

DefinitionBreast-Specific Gamma Imaging (BSGI) is a nuclear medicine technique (also called scintimammography or MBI) performed with a gamma camera after intravenous administration of a radioactive tracer to detect breast tissue with increased radiotracer uptake.

Primary useProposed as an adjunct to mammography and physical exam to improve selection for biopsy in patients with palpable masses or suspicious mammograms

Regulatory noteBSGI equipment (dedicated gamma cameras) is regulated as radiologic devices (Class I); procedure standards and radiation safety guidance are described in SNMMI documents

Computer-Aided Tactile Breast Imaging definition

DefinitionComputer-Aided Tactile Breast Imaging uses a hand-held tactile array sensor moved across the breast and underarm; signals are processed into multidimensional color images that display size, shape, hardness, and location of suspicious masses in real time.

Allowed imaging frequency

Mammography, MRI frequency limits — 1 per calendar year for screening mammogram; annual MRI for qualifying high-risk groups

Screening mammography frequencyOne screening mammogram (film or digital) per calendar year

MRI frequencyAnnual MRI allowed for qualifying high-risk groups (see qualifying criteria)

ApplicabilityFrequency limits apply to breast imaging (mammography and MRI) per state-specific criteria

Not covered / exclusions

Codes marked with an asterisk (*) are not on the LA Medicaid Fee Schedule and therefore are not covered by the State program. Specific modalities associated with those asterisked codes will not be reimbursed under Louisiana Medicaid.

Routine population screening with BSGI/MBI is discouraged by professional guidance: the ACR recommends against BSGI/MBI for screening due to radiation dose concerns, and NCCN does not support routine use of molecular imaging for screening. While this policy does not contain an explicit modality exclusion table for every indication, these guideline positions provide clinical rationale for not authorizing routine screening with BSGI/MBI.

Routine population screening with BSGI/MBI is not supported by guideline statements and is therefore treated as not routinely appropriate in this policy context. The ACR recommendation against screening BSGI/MBI because of higher radiation exposure, together with NCCN guidance, underpins the policy stance that these modalities are not indicated for routine population screening.

Clinical background and rationale

Mammography is recognized as the standard screening modality for breast cancer. MRI and ultrasound are used selectively: MRI is typically reserved for higher-risk patients or when mammography is limited (for example, in women with dense breasts), and ultrasound is commonly used as an adjunct to evaluate palpable findings or to further assess areas of concern identified on mammography.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS010LA.V

Change TypeRetirement and code/coverage revisions

Effective DateFebruary 1, 2026 - March 31, 2026

Next Review DateN/A

SourceLink

On This Page

Meta-analyses report scintimammography sensitivity ~85% and specificity ~84-86%; BSGI sensitivity similar to MRI with higher specificity but higher radiation burden.

Guideline alignment: Professional societies generally support MRI as the supplemental screening method of choice for many high-risk patients; alternatives such as contrast-enhanced mammography (CEM), MBI, or ultrasound may be considered when MRI is not feasible, but societies caution against routine use of molecular imaging for population screening due to radiation and limited outcome evidence.

ACR, NCCN, ACS, SNMMI/EANM and USPSTF positions summarized in policy.

Supplemental screening in high-risk patients who cannot undergo MRI or have dense breasts where MRI/CEM are unavailable

When breast MRI is not feasible or available, certain supplemental modalities may be considered for high-risk patients, though evidence and guidance vary:

MBI/BSGI as alternative: For individuals at increased risk who cannot undergo breast MRI, contrast-enhanced mammography (CEM) or molecular breast imaging (MBI/BSGI) may be considered as supplemental screening, acknowledging limited evidence and higher radiation exposure.

NCCN and SNMMI/EANM statements support consideration of MBI/BSGI when MRI is not possible; assess risks and benefits.

Use of ultrasound as adjunct to mammography in dense breasts or to evaluate palpable findings

Ultrasound may be used as an adjunct to mammography in selected situations:

Ultrasound adjunct use: Breast ultrasound is useful for evaluating palpable lumps and can be helpful in women with dense breast tissue as an adjunct to mammography; it may distinguish cystic from solid lesions and guide further management.

ACS and ACR guidance note ultrasound utility in dense breasts and for palpable findings; ultrasound may be performed when CEM or functional imaging are not available.

Supplemental imaging for mammographically occult disease in dense breasts or when MRI is contraindicated/unavailable

Supplemental imaging options when mammography is occult or MRI is contraindicated/unavailable:

MBI/BSGI for occult disease: MBI/BSGI may detect mammographically-occult breast cancer in women with heterogeneously or extremely dense breasts and in women at elevated risk who are unable to undergo breast MRI; consider radiation exposure and limited outcome data when selecting this option.

SNMMI/EANM 2022 practice guideline notes MBI usefulness in these contexts; USPSTF considers evidence insufficient for routine supplemental screening after a negative mammogram.

Maintain legible records and make available upon request

Billing Rule

Modality sequencing for dense breasts

Providers should follow recommended modality sequencing for beneficiaries with dense breasts: start with diagnostic breast ultrasound as the initial preferred modality for supplemental evaluation; if ultrasound is inconclusive and clinical suspicion persists, consider breast MRI per indications and coverage criteria.

Initial modality for dense breasts: ultrasound
If ultrasound inconclusive: consider MRI per coverage criteria
Note: ACR discourages routine screening with BSGI/MBI; use only when clinically indicated

Documentation Required

Document procedure details and follow radiation safety for breast scintigraphy

When performing breast scintigraphy with dedicated gamma cameras, adhere to procedure standards that include documentation and recording of the examination and compliance with radiation safety requirements.

Documentation Required

Provide documentation that fully supports medical necessity

Medical records documentation may be required to assess whether the member meets clinical criteria for coverage; documentation must fully support medical necessity and be made available upon request.

Denial Risk

Denial risk if documentation is insufficient

Lack of medical record documentation that supports medical necessity may result in denial of the request or generation of a records request during claim review.

Denial Risk

ACR recommendation: BSGI/MBI not recommended for screening — denial risk

The American College of Radiology (ACR) recommends against using BSGI/MBI for screening because of relatively high radiation dose; this recommendation can support denial of screening claims for BSGI/MBI.

Denial Risk

Policy retirement and plan disenrollment implications (LA)

Policy retired for Louisiana plan membership disenrolled on April 1, 2026; claims or prior authorization requests for affected Louisiana membership after that date may be handled differently per plan changes.

Confirm prior authorization rules with governing requirements and plan terms

Verify prior authorization rules with federal, state, or contractual requirements and the member’s plan terms; UnitedHealthcare may apply external criteria or tools when administering prior authorization.

Technology formReal-time tactile sensor with computer-processed color image output for clinician assessment

Intended roleAdjunctive diagnostic tool to help identify palpable or suspicious masses; considered unproven in this policy due to insufficient evidence

Magnetic Resonance Elastography (MRE) definition

DefinitionMagnetic Resonance Elastography (MRE) measures mechanical properties of breast tissue (elastic modulus) using phase-contrast MRI with an electromechanical driver and specialized coil to quantify tissue stiffness.

Measurement principleApplies a known stressor and measures resulting deformation to differentiate stiffer (malignant) from normal tissue

Clinical statusFeasibility studies show quantitative depiction of tissue stiffness, but clinical benefits and diagnostic role remain under evaluation and are considered unproven in this policy

Positron Emission Mammography (PEM) definition

DefinitionPositron Emission Mammography (PEM) is a high-resolution metabolic breast imaging technique that uses an FDG tracer with detectors integrated into a mammography-like system to acquire emission images.

Clinical rolePerforms metabolic imaging for breast cancer and can be used in patients unable to undergo MRI; provides emission images immediately after mammography acquisition

Relation to molecular imagingPEM is a form of molecular/metabolic breast imaging related to MBI/BSGI but uses PET tracers and dedicated mammography-style detectors

CE-CBBCT definition — contrast-enhanced cone-beam breast CT

TermCE-CBBCT = contrast-enhanced cone-beam breast computed tomography

NoteCE-CBBCT protocols in studies used iodinated IV contrast and generally showed higher pooled sensitivity and specificity than non-contrast CBBCT

Evidence statusDiagnostic accuracy of CE-CBBCT reported as numerically comparable to breast MRI in limited studies; further validation required

NC-CBBCT definition — non-contrast cone-beam breast CT

TermNC-CBBCT = non-contrast cone-beam breast computed tomography

Performance notePooled sensitivity 0.789 and specificity 0.697 reported in systematic review of NC-CBBCT studies

Evidence statusNC-CBBCT showed lower diagnostic performance than CE-CBBCT; evidence limited and heterogeneous

MRE shorthand — magnetic resonance elastography of the breast

ShorthandMRE = magnetic resonance elastography of the breast

PurposeUsed to denote phase-contrast MRI elastography techniques assessing breast tissue stiffness

Policy statusListed as unproven / not medically necessary pending further validation

BSGI/MBI shorthand — breast-specific gamma imaging / molecular breast imaging

ShorthandBSGI / MBI = breast-specific gamma imaging / molecular breast imaging

Clinical noteMBI/BSGI can detect mammographically-occult cancers in dense breasts but carries higher radiation burden; professional societies caution routine screening use

Guideline referenceSNMMI/EANM 2022 practice guideline recognizes MBI usefulness when MRI is not feasible

BSGI / MBI extended definition

Extended definitionNuclear medicine breast imaging using dedicated gamma cameras (BSGI/MBI/scintimammography) images radionuclide distribution in the breast after IV radiotracer administration.

Procedure characteristicsFunctional/metabolic imaging that highlights tissue with increased tracer uptake and is intended as an adjunct to anatomical imaging

Safety and standardsSNMMI procedure standards (2010) emphasize documentation, recording, quality control, and radiation safety for breast scintigraphy