UnitedHealthcare breast MRI Coverage Update

Medically Necessary and Not Medically Necessary Criteria

Medically necessary: Breast MRI for screening

Breast MRI is proven and medically necessary for individuals who are high risk for breast cancer as defined by any of the following:

ANY of the following

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% using models largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO)
Screening beginning at age 40; see age modifier below
Personal history of breast cancer (not treated with bilateral mastectomy)
Personal history with specific gene mutations
- ATM mutation
  Screening beginning at age 30*
- BARD1 mutation
  Screening beginning at age 40*
- BRCA1 or BRCA2 mutation
  Screening beginning at age 25
- CDH1 mutation
  Screening beginning at age 30*
- CHEK2 mutation
  Screening beginning at age 30*
Family history criteria
- At least one first-degree relative with a BRCA1 or BRCA2 mutation
  Screening beginning at age 40*
- First-degree relative who carries a TP53 or PTEN mutation (Li-Fraumeni, Cowden, Bannayan-Riley-Ruvalcaba, or Peutz-Jeghers syndrome)
- At least two first-degree relatives with breast or ovarian cancer
  Screening beginning at age 40*
- One first-degree relative with bilateral breast cancer, or both breast and ovarian cancer
  Screening beginning at age 40*
- First- or second-degree male relative (father, brother/half-brother, uncle, grandfather) diagnosed with breast cancer
  Screening beginning at age 40*

ALL of the following

Documented high-risk status (e.g., model estimate >= 20% or qualifying family history/genetic mutation) as required in policy

Age modifier for family-based earliest screening

Special age rule applying to several criteria above:

ALL of the following

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 (up to third-degree relatives), whichever comes first
But not before age 25

Not medically necessary / unproven

The following modalities/indications are unproven and not medically necessary due to insufficient evidence of efficacy:

ANY of the following

Computer-Aided Tactile Breast Imaging (e.g., tactile imaging devices)
Computed tomography (CT) of the breast
Magnetic Resonance Elastography (MRE) of the breast
MRI of the breast for individuals who do not meet the high-risk criteria above
Molecular Breast Imaging (MBI) / Breast Specific Gamma Imaging (BSGI) / scintimammography / Positron Emission Mammography (PEM)

Indications and guideline-based summaries for supplemental breast imaging

Guideline statements summarized from professional societies describing when supplemental imaging may be considered:

Modalities and guideline recommendations

Breast ultrasound: Can be considered in high-risk women for whom MRI screening may be appropriate but who cannot have MRI for any reason.
Breast ultrasound: Can be considered in women with dense breast tissue as an adjunct to mammography (SBI/ACR 2010 statement).
Molecular Breast Imaging (MBI) / BSGI: SNMMI/EANM (2022) notes MBI has been useful detecting mammographically-occult cancers in women with dense breasts and in elevated-risk women who are unable to undergo MRI.
SNM (2010) breast scintigraphy guideline: Further study needed to determine populations most likely to benefit; guideline focuses on procedure specifications and quality control.

UnitedHealthcare MRI of the breast - high-risk screening criteria (summary of revisions referenced)

Screening MRI for individuals at high risk is covered when criteria (as revised) are met:

ALL of the following

Lifetime risk estimated >= 20% as defined by models largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO).
ANY of the following
- At least one first-degree relative with a BRCA1 or BRCA2 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.

Not medically necessary / Unproven (summary as revised)

Policy states that certain services are unproven or not medically necessary when they do not meet the policy criteria:

ALL of the following

MRI of the breast for individuals who do not meet the criteria listed in the policy is considered not medically necessary.

Numeric and Operational Thresholds

Screening thresholds and age rules

Lifetime risk threshold>= 20% (models largely dependent on family history, e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO)

Chest radiation dose for radiation-exposed screeningPrior thoracic radiation between ages 10 and 30; start screening at age 25 or 8 years after treatment, whichever is later

Age for BRCA mutation carriersBegin MRI screening at age 25

Minimum age via family-history early ruleDo not start screening earlier than age 25 even when using the '10 years before youngest relative' rule

Screening start age for certain criteriaAge 40 (or 10 years prior to the youngest relative's diagnosis, whichever comes first; not before age 25)

Codes Mentioned in Policy

CT and related 3D rendering codes (listed in policy)CPT

0633T	Computed tomography, breast, including 3D rendering, unilateral; without contrast material
0634T	Computed tomography, breast, including 3D rendering, unilateral; with contrast material(s)
0635T	Computed tomography, breast, including 3D rendering, unilateral; without contrast, followed by contrast material(s)
0636T	Computed tomography, breast, including 3D rendering, bilateral; without contrast material(s)
0637T	Computed tomography, breast, including 3D rendering, bilateral; with contrast material(s)
0638T	Computed tomography, breast, including 3D rendering, bilateral; without contrast, followed by contrast material(s)
76376	3D rendering with interpretation — concurrent supervision; not requiring independent workstation
76377	3D rendering with interpretation — requiring independent workstation

MRE and MRI CPT codesCPT

76391	Magnetic resonance (e.g., vibration) elastography
76498	Unlisted magnetic resonance procedure
77046	MRI, breast, without contrast; unilateral
77047	MRI, breast, without contrast; bilateral
77048	MRI, breast, without and with contrast; unilateral (includes CAD when performed)
77049	MRI, breast, without and with contrast; bilateral (includes CAD when performed)

Computer-aided tactile imagingCPTExperimental

0422T

Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral

Molecular breast imaging / scintimammographyHCPCS|CPTExperimental

S8080

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

Codes mentioned in document text or contextmixed

No codes listed

Documentation, Billing, and Operational Requirements

Documentation Required

Medical record documentation

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; records must be legible, maintained in the patient's medical record, and made available upon request.

Billing Rule

Coding clarification for MRI CAD

Computer-aided detection (CAD) is included with the MRI breast CPT codes 77048 and 77049; when CAD is performed with these codes there is no additional reimbursement.

77048
77049

Clinical and Guideline Context

Mammography remains the accepted standard for population breast cancer screening; this policy does not address routine screening mammography but focuses on the role of supplemental imaging to improve cancer detection in specific populations (e.g., individuals at elevated lifetime risk and those with dense breasts). Supplemental imaging is considered primarily to improve detection where mammography has known limitations, such as in heterogeneously or extremely dense breast tissue and in people at high genetic or treatment-related risk for breast cancer.

The policy identifies breast MRI as a proven, medically necessary adjunctive screening modality for individuals meeting defined high-risk criteria, including heterogeneously dense (Category C) or extremely dense (Category D) breasts (screening beginning at age 40), prior thoracic radiation between ages 10 and 30 (screening starting at age 25 or 8 years after treatment), and model-estimated lifetime risk of ≥ 20% (models largely dependent on family history, e.g., Gail, Claus, Tyrer-Cuzick, BRCAPRO), as well as specified personal and family genetic-risk scenarios. Age-specific starting ages for certain genetic mutations and family-history–based earlier screening (up to 10 years before the youngest relative’s diagnosis but not before age 25) are included in the policy.

The evidence base summarized in the policy shows higher cancer detection and reduced interval cancer rates with supplemental MRI in select subgroups, but also higher recall and biopsy rates; randomized trials and systematic reviews demonstrate an incremental cancer detection rate advantage for MRI versus mammography and variable effects for ultrasound (higher false positives). Guidelines from multiple professional societies are referenced: the ACR and SBI support MRI or ultrasound as appropriate supplemental strategies based on risk and density; the NCCN and ACR note MRI as the preferred supplemental modality for most high-risk patients; SBI/ACR, ACS, ACOG, SNMMI/EANM, and EUSOBI recommendations and statements are summarized to align when supplemental imaging may be considered and to note areas where evidence is limited or evolving.

Other adjunctive modalities—such as computed tomography (CT) of the breast, magnetic resonance elastography (MRE), molecular breast imaging/BSGI/scintimammography/PEM, and computer-aided tactile breast imaging—are considered unproven or not medically necessary for routine supplemental screening because available studies are low quality, limited in size or generalizability, or do not demonstrate improved patient outcomes compared with established approaches. The policy therefore restricts coverage for these modalities outside defined indications and emphasizes documentation of medical necessity and the specific clinical rationale when alternatives to MRI are used.

Defined Terms

Definitions

Breast Composition CategoriesACR BI-RADS categories: A = almost entirely fatty; B = scattered fibroglandular density; C = heterogeneously dense; D = extremely dense

Molecular Breast Imaging (MBI) / BSGI / ScintimammographyFunctional imaging using radioactive tracers and a gamma camera to detect increased tracer uptake in breast tissue (performed after IV administration of radioactive tracers)

Magnetic Resonance Elastography (MRE)Phase-contrast-based MRI technique quantifying mechanical properties (stiffness) of tissues for characterization

Positron Emission Mammography (PEM)High-resolution metabolic imaging of the breast using an FDG tracer with detectors integrated into a mammography system

Computer-Aided Tactile Breast ImagingTactile array sensor moved across the breast producing multi-dimensional images representing size, shape, hardness, and location of suspicious masses

Breast Composition Categories (policy restatement)

Policy Changes and Material Revisions

04/01/2026revisedLatest

Revised coverage criteria for breast MRI for individuals at high risk: added requirement for heterogeneously or extremely dense breasts (Category C or D) with screening beginning at age 40; specified lifetime-risk and family-history criteria with screening beginning at age 40 for several family-history–based entries; clarified that screening can begin at the listed age or 10 years prior to the youngest relative's diagnosis (up to third-degree relatives), whichever comes first, but not before age 25; updated the list of unproven/not medically necessary services to state that MRI is not covered for individuals who do not meet the policy criteria; and updated supporting evidence and references.

04/01/2026revised

Clarified that MRI for density alone is not covered unless other policy criteria are met by replacing prior phrasing with 'MRI of the breast for individuals who do not meet the criteria [listed in the policy]'.

OpenPayer

Breast Imaging for Screening and Diagnosing Cancer (for New Mexico Only)

Medically Necessary and Not Medically Necessary Criteria

Numeric and Operational Thresholds

Codes Mentioned in Policy

Documentation, Billing, and Operational Requirements

Clinical and Guideline Context

Defined Terms

Policy Changes and Material Revisions