CurrentUnitedHealthcarePolicy CSRAD002OH.D

Breast Imaging Guidelines (For Ohio Only)

UnitedHealthcare Community Plan clinical guidelines for breast and related imaging applicable only to members in Ohio, covering modality-specific guidance (US, CT, MRI, PET), documentation requirements, investigational criteria, coding/billing guidance, and procedural coding instructions.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD002OH.D

Change TypeAnnual/interim evidence-based updates

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit recent detailed history, physical exam since onset/change in symptoms, laboratory and prior imaging studies, and other pertinent medical records to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — policy history notes annual and interim evidence-based updates (02/01/2024, 07/01/2024, 05/01/2025) but has_material_change=false.

State-limitedGeographic Scope

V1.0.2025Guideline Version

ListedHigh-risk MRI Screening

Not indicatedWhole-body CT/MRI screening

InvestigationalQuantitative mpMRI Category III

Coverage Summary

This policy (Guideline Number: CSRAD002OH.D, Effective Date: November 1, 2025) applies only to the state of Ohio and provides evidence-based guidance for advanced breast imaging modalities including ultrasound (US), CT, MRI, and PET. It is reviewed annually and based on national society guidance and literature; the guideline supports case-by-case decisions and allows clinician judgment to override the guidance when appropriate. The coverage stance is mixed and the guideline explicitly lists high-risk MRI screening criteria (genetic mutations, personal/family history, lifetime risk thresholds) for annual MRI screening and supports MRI Breast bilateral with and without contrast when criteria are met.

Medical Necessity Criteria and Modality Guidance

Application / Medical Necessity Determination

Application / Medical Necessity Determination (Ohio): This policy applies only in Ohio. Requests for services stated as unproven or with coverage, age, timeframe, or quantity limits will be evaluated per Ohio Administrative Code 5160-1-01. Determinations are case-by-case based on personal/family history, physical exam, and presenting symptoms or changes.

All imaging requests must include recent clinical evaluation (history and physical) since onset or change in symptoms unless request is for guideline-supported scheduled follow-up.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Imaging Guidelines (For Ohio Only)

Policy CodePolicy CSRAD002OH.D

Change TypeAnnual/interim evidence-based updates

Effective DateNov 1, 2025

Next Review Date

Key ActionSubmit recent detailed history, physical exam since onset/change in symptoms, laboratory and prior imaging studies, and other pertinent medical records to establish medical necessity.

SourceLink

On This Page

Ohio Administrative Code 5160-1-01 will be used to evaluate services stated as unproven or subject to limits.

Case-by-case determinations incorporate individual risk factors, exam findings, and prior studies; deviation from guideline recommendations requires clear documentation of medical necessity.

Clinical Documentation Requirements (General)

Clinical Documentation Requirements (General): Submit adequate clinical information to establish medical necessity.

A recent detailed history and focused physical examination (since onset or change in symptoms).

Pertinent laboratory data when relevant (e.g., prolactin for galactorrhea, tumor markers when applicable).

Prior imaging studies and reports (mammography, ultrasound, MRI, CT, PET) with dates and outcomes; compare with prior studies when available.

Condition-specific information per guideline section (e.g., genetic test results, implant history, biopsy pathology).

Documentation of prior interventions, consultations, and other meaningful technological contacts (telehealth, phone, messaging) since onset or change in symptoms.

Investigational / Experimental Criteria

Investigational / Experimental Criteria: Defines when a procedure or device is considered investigational/unproven.

Considered investigational if there is a paucity of supporting evidence or lack of mature evidence demonstrating improved health outcomes.

Considered investigational if clinical utility has not been demonstrated in any condition or lacks collective opinion of support from relevant specialty societies.

Clinical trial imaging consistent with data collection only and not used in direct clinical management is not supported unless it meets statute and plan criteria.

Modality-Specific Considerations: CT

Use dedicated breast CT only when indicated by guideline-supported reasons; whole-body CT considerations addressed in Whole-Body CT/MRI and PET-MRI block.

CT-guided breast procedures follow Imaging Guidance Procedure Codes and Guidance/Interventional Imaging Coding Rules for appropriate coding and justification.

Limited or follow-up CT (CPT 76380) is supported only for targeted re-imaging when prior full study exists and the clinical question can be answered by a limited field of view.

Modality-Specific Considerations: MRI

Breast MRI indications follow BR-5.1 criteria (high-risk screening, problem-solving, staging, treatment planning, post-therapy surveillance as specified).

MRI-guided biopsy and MRI guidance procedural coding must be used when biopsy is performed under MR guidance; see MRI-guided Biopsy and Coding (BR-2.1) block for codes and requirements.

Whole-body MRI for systemic staging follows Whole-Body CT/MRI and PET-MRI guidelines; breast MRI outside those indications requires documentation of specific medical necessity.

Modality-Specific Considerations: Ultrasound

Breast ultrasound is first-line for palpable masses, focal pain, or targeted problem solving and for evaluation in pregnant or lactating individuals per BR-10.1.

Ultrasound guidance for procedures follows Imaging Guidance Procedure Codes and Guidance/Interventional Imaging Coding Rules; document lesion localization and procedural necessity.

Supplemental screening ultrasound for dense breasts may be supported per risk and screening criteria; routine surveillance ultrasound is not supported unless specified.

Modality-Specific Considerations: PET

PET and PET-MRI for breast cancer staging or systemic evaluation follow Whole-Body CT/MRI and PET-MRI guidelines; not indicated for primary breast lesion characterization when other modalities suffice.

MBI (Molecular Breast Imaging) may be considered as an alternative when MRI is contraindicated per MBI criteria block; PET-based breast imaging techniques such as PEM are listed as unsupported in Alternative Approaches.

Overutilization Precautions

Overutilization Precautions: Avoid unnecessary or duplicative imaging.

Do not perform advanced imaging without appropriate clinical evaluation unless for guideline-supported scheduled follow-up.

Avoid duplicate imaging modalities unless prior study was non-diagnostic or modality-specific information is clinically required.

Prior authorization and documentation requirements apply; failure to provide required documentation may result in denial.

When MRI Breast is NOT Indicated

When MRI Breast is NOT Indicated: Any of the following are NOT supported by MRI breast.

MRI is not indicated for routine screening of average-risk individuals.

MRI is not indicated for evaluation of diffuse breast pain without focal findings after mammography/ultrasound per BR-7.1.

MRI is not indicated for routine surveillance of breast implants (prohibitions on routine surveillance addressed in BR-5.2 Breast Implant Evaluation).

MRI is not indicated when the clinical question can be answered by mammography or targeted ultrasound.

MRI Breast Indications (BR-5.1)

MRI Breast Indications (BR-5.1): Supported indications include high-risk screening, problem-solving for equivocal mammogram/US, staging, and post-biopsy or post-treatment assessment per BI-RADS guidance.

High-risk screening: annual MRI in addition to mammography for individuals with any of the following:

Any of: documented deleterious BRCA1/BRCA2 mutation; or first-degree relative with known BRCA mutation when patient is untested but meets family history criteria;

Any of: lifetime risk >= 20% (per validated models that incorporate family history), history of chest irradiation between ages 10-30, or certain high-risk genetic syndromes as listed in policy.

Problem-solving: MRI may be supported when mammogram and targeted ultrasound are equivocal for extent of disease or when additional information will change management (surgical planning, multifocality).

BI-RADS follow-up and post-biopsy imaging: MRI support for discrepant or discordant findings when prior imaging/biopsy is indeterminate or to assess residual disease after lumpectomy when indicated.

Breast Ultrasound (BR-1.1) - Indications and Follow-up

Breast Ultrasound (BR-1.1) - Indications and Follow-up: Initial imaging and supplemental screening guidance.

Initial evaluation of palpable mass, focal breast symptoms (pain, focal tenderness), or suspicious nipple discharge: diagnostic mammography and targeted ultrasound as first-line.

Supplemental screening ultrasound may be considered in women with dense breasts and elevated risk per screening criteria; document risk assessment and prior mammography.

BI-RADS follow-up: ultrasound surveillance schedule and interventions should follow BI-RADS recommendations; biopsy indicated for suspicious (BI-RADS 4/5) findings.

MRI Screening for High-Risk Individuals

MRI Screening for High-Risk Individuals: Annual screening criteria and age thresholds with nested genetic and non-genetic groupings.

All of: Annual MRI screening in addition to mammography is supported for individuals with any of the following high-risk categories:

Any of (Genetic-related): Known pathogenic/likely pathogenic mutation in BRCA1/BRCA2, TP53, PTEN, PALB2, or other high-penetrance genes as specified; or history of prior chest irradiation between ages 10-30.

Any of (Non-genetic high-risk): Lifetime risk >= 20% by validated models that use family history (e.g., Tyrer-Cuzick), history of lobular carcinoma in situ (LCIS), or other specified high-risk lesions per policy.

Age thresholds: Typically begin MRI screening at age 25-30 for genetic high-risk (e.g., BRCA) or 8 years after chest irradiation (but not before age 25); for non-genetic high-risk use age thresholds described in policy and individualize based on risk model.

Molecular Breast Imaging (MBI)

Molecular Breast Imaging (MBI): Indications and conditional support.

MBI may be considered as an alternative supplemental screening modality when MRI is contraindicated or not tolerated and when supplemental imaging is indicated based on risk/dense breasts.

MBI is considered investigational/experimental for routine screening when MRI and other guideline-supported modalities are available and not contraindicated.

MBI use must be supported by documentation that MRI is contraindicated (e.g., incompatible device, severe claustrophobia unmanageable by sedation) and prior imaging results that justify supplemental evaluation.

Breast Implant Evaluation (BR-5.2)

Breast Implant Evaluation (BR-5.2): Age-based algorithms and imaging approach for silicone and saline implants.

Implant integrity evaluation: MRI without contrast is the preferred modality for suspected silicone implant rupture when clinical concern exists; routine surveillance imaging of implants is not supported.

Saline implants with suspected rupture: clinical exam and ultrasound are often sufficient; confirmatory imaging per clinical judgment.

MRI without contrast may be supported for symptomatic implant evaluation (pain, new lump, change in contour) or when ultrasound is nondiagnostic.

Prohibition: Routine MRI surveillance of implants in asymptomatic individuals is not supported.

Nipple Discharge / Galactorrhea (BR-6.1)

Nipple Discharge / Galactorrhea (BR-6.1): Distinguish pathologic from physiologic discharge and required imaging sequence.

All of: For pathologic nipple discharge (spontaneous, unilateral, bloody or serous), perform diagnostic mammography and targeted ultrasound as first-line.

Any of: If mammography and targeted ultrasound are non-diagnostic and clinical concern persists, MRI breast per BR-5.1 may be supported.

Physiologic galactorrhea (bilateral, milky, associated with medications or systemic causes): obtain appropriate labs (e.g., prolactin) and perform imaging only if focal suspicious features are present.

Breast Pain (Mastodynia) (BR-7.1)

Breast Pain (Mastodynia) (BR-7.1): Evaluation pathway.

All of: Initial management includes history and physical examination; diagnostic mammography and targeted ultrasound if focal or persistent pain or if >30 years per routine practice.

Any of: MRI is not routinely indicated for mastodynia and is supported only if indicated per BR-5.1 (e.g., persistent focal abnormality not resolved by mammography/US).

Alternative Breast Imaging Approaches (BR-8.1)

Alternative Breast Imaging Approaches (BR-8.1): Unsupported techniques and notes.

Not supported: Positron Emission Mammography (PEM), thermography, optical imaging, and CT of the breast for routine diagnostic or screening purposes.

CT breast and other non-standard CT techniques for primary breast evaluation are not supported except in exceptional cases documented per Whole-Body CT/MRI guidance.

MBI note: MBI may be conditionally supported when MRI is contraindicated; otherwise considered investigational for routine use.

Suspected Breast Cancer in Males (BR-9.1)

Suspected Breast Cancer in Males (BR-9.1): Initial evaluation and biopsy requirement.

All of: Males with a palpable suspicious mass should undergo diagnostic mammography and targeted ultrasound as initial studies.

Any of: Suspicious imaging (BI-RADS 4 or 5) requires tissue diagnosis (core needle biopsy) for definitive evaluation; imaging alone is insufficient.

Breast Evaluation in Pregnant or Lactating Females (BR-10.1)

Breast Evaluation in Pregnant or Lactating Females (BR-10.1): Imaging approach and safety considerations.

All of: Ultrasound is first-line for evaluation of breast symptoms in pregnant and lactating individuals.

Any of: Diagnostic mammography may be performed when clinically indicated with abdominal and pelvic shielding; do not delay when results will change management.

Gadolinium-based contrast agents are contraindicated in pregnancy except in rare circumstances with documented necessity; MRI may be performed without contrast if necessary.

In lactating individuals, MRI with gadolinium is allowed per BR-5.1 indications; breastfeeding need not be interrupted unless specific agent guidance requires it.

3D Rendering (CPT 76376/76377) Criteria

3D Rendering (CPT 76376/76377) Criteria: Use and coding guidance.

3D rendering (CPT 76376/76377) is supported only when additional 3D post-processing materially changes clinical management (surgical planning, complex reconstruction) beyond the native multiplanar images.

Documentation must state how the 3D rendering influenced management; routine or cosmetic 3D renderings without clinical justification are not supported.

When billed, use appropriate CPT 76376 (computer-aided rendering without interpretation) or 76377 (with interpretation) per coding guidance and local payer rules; consult Guidance/Interventional Imaging Coding Rules for bundling and modifier use.

Imaging Guidance Procedure Codes (CT/MR/US guidance)

Imaging Guidance Procedure Codes (CT/MR/US guidance): Coding and documentation requirements for image-guided breast procedures.

Use modality-specific guidance codes for procedural localization and biopsy (e.g., ultrasound guidance, stereotactic guidance, CT or MR guidance) and document lesion localization, approach, and needle placement.

Guidance codes should reflect the imaging modality used (US, CT, MR) and whether contrast or additional imaging was required for guidance; follow Guidance/Interventional Imaging Coding Rules for bundling.

Separate guidance and biopsy/drainage codes may be reported when documentation supports distinct services; appropriate modifiers must be used per payer coding rules.

Breast Reconstruction Imaging (BR-3.1)

Breast Reconstruction Imaging (BR-3.1): Imaging for reconstruction planning and complications.

Preoperative imaging for breast reconstruction planning (implant-based or autologous) is supported when results will change surgical approach; document specific questions to be answered by imaging.

Postoperative imaging for suspected complications (hematoma, seroma, infection, flap compromise) is supported; choose modality based on clinical scenario (US for fluid collections, CT/MRI for complex soft tissue/flap evaluation).

Routine imaging solely for cosmetic surveillance after satisfactory reconstruction is not supported.

MRI-guided Biopsy and Coding (BR-2.1)

MRI-guided Biopsy and Coding (BR-2.1): Requirements and coding rules.

MRI-guided biopsy is supported when a target lesion is only visualized on MRI and not accessible or targeted by ultrasound, stereotactic, or mammographic guidance.

Document prior attempts or reasons why other guidance modalities are unsuitable and that MRI-guided biopsy will change management.

Appropriate CPT codes for MR-guided breast biopsy and associated guidance must be used; follow Guidance/Interventional Imaging Coding Rules for bundling, and submit pathology correlation documentation.

When available, report facility and physician services with correct modifiers; unlisted or additional device charges must be justified in documentation.

Whole-Body CT/MRI and PET-MRI (Preface 5.1-5.3)

Whole-Body CT/MRI and PET-MRI (Preface 5.1-5.3): Systemic imaging considerations.

Whole-body CT/MRI and PET-MRI for staging or systemic evaluation of known breast cancer should follow Preface Whole-Body imaging guidance and be supported by clinical need (symptoms, suspected metastases, or staging that changes management).

Do not use whole-body imaging for localized breast problem-solving when dedicated breast imaging (mammography, targeted US, dedicated breast MRI) will answer the question.

PET-MRI may be considered in select cases where combined metabolic and high-resolution anatomic information will alter management; documentation of expected incremental value is required.

Guidance/Interventional Imaging Coding Rules

Guidance/Interventional Imaging Coding Rules (Preface-CT/MR guidance & others): Billing and bundling principles.

Follow CPT and payer-specific rules for reporting guidance and interventional procedures; do not unbundle services that are inclusive per coding conventions.

When guidance is inherent to the primary procedure (per CPT definitions), separate guidance codes should not be submitted unless documentation supports an additional distinct guidance service.

Use appropriate modifiers to indicate separate physician and facility services and to identify multiple procedures when medically necessary.

Unlisted Procedure Codes (Preface-4.3)

Unlisted Procedure Codes (Preface-4.3): Use and documentation.

Unlisted procedure codes require submission of detailed operative/imaging reports, rationale for use, and comparative literature or references when applicable.

Provide expected CPT equivalents, detailed description of the service performed, and justification for why a listed code does not accurately describe the service.

Unlisted codes are subject to additional review and may be denied if documentation is insufficient.

CPT 76380 Limited or Follow-up CT (Preface-4.5)

CPT 76380 Limited or Follow-up CT (Preface-4.5): When to use limited CT coding.

CPT 76380 may be reported for limited-field CT re-imaging when a prior full CT exists and the limited study is sufficient to answer the specific clinical question; document prior study and rationale.

Do not use CPT 76380 to circumvent full examination when full-field imaging is clinically indicated.

Ensure documentation clearly specifies the limited region imaged and the targeted clinical question.

Phyllodes Tumor Imaging

Phyllodes Tumor Imaging: Imaging and management considerations.

For suspected phyllodes tumor, initial imaging with diagnostic mammography and targeted ultrasound is appropriate; core biopsy is recommended for tissue diagnosis.

Cross-sectional imaging (MRI or CT) may be used for large tumors to assess local extent and chest wall involvement for surgical planning; document how imaging will change management.

Phyllodes tumors often require wide local excision; preoperative imaging should focus on size and extent to guide reconstruction planning.

Coding Guidance and Code Groups

3D Rendering / Post-processing CodesCPTCovered

76376	3D rendering, not requiring image post-processing on an independent workstation
76377	3D rendering, requiring image post-processing on an independent workstation

3D Rendering (restrictions) - not_coveredCPTNot Covered

76376	Do not bill with any 3D mammography code, breast ultrasound (including ABUS), MRI Breast, CAD, MRA, CTA, SPECT, PET or PET/CT
76377	Do not bill with any 3D mammography code, breast ultrasound (including ABUS), MRI Breast, CAD, MRA, CTA, SPECT, PET or PET/CT

Quantitative mpMRI Category III codes - experimentalCPTExperimental

0648T	Quantitative mp-MRI analysis without diagnostic MRI (single organ) - investigational/experimental
0649T	Quantitative mp-MRI analysis with diagnostic MRI (single organ) - investigational/experimental
0697T	Quantitative mp-MRI analysis without diagnostic MRI (multiple organs) - investigational/experimental
0698T	Quantitative mp-MRI analysis with diagnostic MRI (multiple organs) - investigational/experimental
0865T	Volumetric/quantitative MRI analysis of brain - considered not medically necessary
0866T	Volumetric/quantitative MRI analysis of brain - considered not medically necessary

MRI Breast supported codes - coveredmixedCovered

77049	MRI Breast Bilateral, including CAD, with and without contrast
C8908	HCPCS MRI Breast Bilateral, with and without contrast
77047	MRI Breast Bilateral, without contrast (supported for implant integrity when indicated)

MRI-guided breast biopsy and add-on codes - coveredCPTCovered

19085	Biopsy, breast, percutaneous; first lesion, including MR guidance (includes imaging component and needle placement)
19086	Biopsy, breast, percutaneous; each additional lesion, including MR guidance
77021	MR guidance for needle placement - NOT appropriate to bill for breast biopsy (policy states 77021 is not appropriate for breast biopsy)

Breast Ultrasound - coveredCPTCovered

76641	Ultrasound, breast, unilateral, complete
76642	Ultrasound, breast, unilateral, limited
76882	Ultrasound, axilla
19083	US-guided breast biopsy (includes imaging component)
19084	Additional lesions for US-guided breast biopsy

SPECT/CT and PET - coveredCPTCovered

78830	SPECT/CT single area single day
78831	SPECT/CT 2 or more days
78832	SPECT/CT 2 areas one day and 2-day study
78813	PET Whole-Body (used in PET-MRI reporting combination)
78072	SPECT/CT parathyroid nuclear imaging

Unlisted CT/MR/nuclear - covered/neutralCPT

76497	Unlisted CT procedure (diagnostic or interventional)
76498	Unlisted MR procedure (diagnostic or interventional); report WBMRI with 76498
78999	Unlisted diagnostic nuclear medicine procedure

Guidance codes (CT/MR/US/fluoroscopy) - billing_rulesCPT

77012	CT guidance for needle placement (contains imaging necessary to guide needle; only one unit per encounter)
77013	CT guidance for, and monitoring of, parenchymal tissue ablation (only for non-bone ablation procedures)
77022	MR guidance for, and monitoring of, parenchymal tissue ablation (includes monitoring, repositioning, confirmation)
77021	MR guidance for needle placement (not appropriate for breast biopsy)
76942	Ultrasonic guidance for needle placement
77002	Fluoroscopy guidance example - unit rules apply (77002-77003 range)
77003	Fluoroscopy guidance example - unit rules apply (77002-77003 range)
75989	Imaging guidance for percutaneous drainage with catheter left in place (all modalities)
77011	CT guidance for stereotactic localization (technical-only in many cases; do not report with 70486 in same session)

Unlisted CT/MR/nuclearCPT

76497	Unlisted CT procedure
76498	Unlisted MR procedure (including WBMRI reporting)
78999	Unlisted diagnostic nuclear medicine procedure

Limited/Follow-up CT (76380) - coveredCPTCovered

76380

Limited or follow-up CT scan when full diagnostic work not performed (e.g., limited slices)

Molecular Breast Imaging / Nuclear BreastCPT

78800	Molecular Breast Imaging (MBI) — supported when MRI screening criteria met but MRI contraindicated
78811	PEM (discussed; generally not recommended for screening/diagnosis and often requested as CPT 78811)

MRI Breast CAD/3D reconstruction (not_covered)HCPCS|CPTNot Covered

C8937	CAD including computer algorithm analysis of MRI Breast data — NOT necessary and considered investigational
76376	3D reconstruction — NOT indicated for breast ultrasound or MRI or with CAD
76377	3D reconstruction — NOT indicated for breast ultrasound or MRI or with CAD

Diagnostic Mammogram codes - coveredCPTCovered

77047	MRI without contrast used for implant integrity when indicated (listed here as diagnostic/implant assessment)
77049	MRI Breast bilateral with and without contrast (supported when indicated)
0633T	CT Breast (codes 0633T-0638T noted as investigational/not supported)

Mammography / Supplemental / Othermixed

77047

MRI Breast bilateral without contrast (implant evaluation)

Surgical planning / Reconstruction imagingCPTCovered

74175	CTA abdomen/pelvis example codes for perforator mapping (DIEP)
74185	MRA abdomen/pelvis example for perforator mapping
71275	CTA Chest (routine use NOT indicated except prior surgery/vascular anomalies)

PET-MRI reporting (when appropriate) - billing_rulesCPT

78813	PET Whole-Body — used with CPT 76498 to report PET-MRI when criteria met
76498	Unlisted MR procedure — used with 78813 for PET-MRI reporting as specified

Other Guidance / Imaging Codes MentionedCPT

70486	CT diagnostic example (do not bill with 77011 same session)
20982	CT guidance for bone tumor ablations (note 77013 not for bone)

Unlisted CT/MR/nuclear (duplicate listing) - coveredCPTCovered

76497	Unlisted CT procedure
76498	Unlisted MR procedure
78999	Unlisted diagnostic nuclear medicine procedure

3D Rendering - billing/physician supervision (documentation)CPTCovered

76376	Requires concurrent physician supervision/participation in post-processing; documentation recommended
76377	Requires concurrent physician supervision/participation in post-processing; documentation recommended

PET/CT and PET-MRI - billing rulesCPT

78813	Report PET/CT as combined study; unbundling PET/CT into separate PET and diagnostic CT codes is not supported
76498	Use with 78813 to report PET-MRI when criteria met

CT Breast / PEM / Other investigational - not_supportedCPTNot Covered

0633T	CT Breast (0633T-0638T) — investigational/not supported for screening/diagnosis
78811	PEM — usually not appropriate and not supported for screening or diagnosis

Guidance code unit rules - billing_rulesCPT

77012	Only one unit of guidance codes should be reported per encounter; unit is the encounter not number of lesions
77021	Only one unit per encounter; 77021 not appropriate for breast biopsy
76942	Ultrasound guidance - one unit per encounter
77002	Fluoroscopy guidance example - one unit per encounter

Limited CT (76380) - billing_ruleCPT

76380

Limited or follow-up CT — not to be reported with other diagnostic CT codes to cover extra slices

Breast MRI supported indications - coveredCPT|HCPCSCovered

77049	Annual screening/diagnostic MRI bilateral with and without contrast when high-risk criteria met
C8908	HCPCS MRI Breast Bilateral with and without contrast
77047	MRI Breast without contrast supported for implant integrity when indicated

Billing rules summary: guidance and post-processing codes are constrained — report only a single unit of imaging guidance codes per encounter (the unit is the encounter, not per lesion) and do not routinely bill a diagnostic code in conjunction with CT/MR/US guidance. Do not unbundle PET/CT into separate PET and diagnostic CT CPT codes; PET/CT should be reported as the combined study. Whole-body MRI should be reported using CPT 76498 only. CPT 76380 describes limited or follow-up CT and has caveats: it is not for treatment planning and must not be used to cover 'extra slices' with other diagnostic CT codes. 3D rendering (CPT 76376/76377) should not be billed with MRI Breast, breast ultrasound, or any 3D mammography codes and requires documented concurrent physician supervision when used.

Provider Actions and Billing Rules

Documentation Required

Submit pertinent clinical information

Submit complete, pertinent clinical information to support medical necessity decisions. Include recent history, physical exam, symptom onset/change, prior imaging, laboratory data, risk assessment, and documentation of breast density laws where applicable.

Pertinent clinical evaluation: recent detailed history and physical exam, symptom onset/change, and prior imaging/labs
Breast density laws: document patient notification and supplemental imaging discussions per Ohio requirements
Do not pair 3D rendering with 3D mammography, MRI, or ultrasound — 3D rendering is a separate post-processing service

Prior Authorization

Prior authorization may be required for 3D rendering codes

Prior authorization may be required for 3D rendering codes. Confirm authorization status before performing services billed with CPT 76376 or 76377.

Codes: 76376, 76377
Check prior auth requirements per plan/contract before scheduling

Billing Rule

Guidance code billing per encounter

Guidance code billing rules: bill guidance codes per encounter and follow unit-of-service limits. Guidance codes associated with the imaging encounter should be billed only once per encounter.

Guidance codes: 77012, 77021, 76942, 77002, 77003, 77013, 77022
Unit of service rule: one unit per encounter

Billing Rule

Do not bill diagnostic code with guidance code / Do not unbundle PET/CT

Do not bill diagnostic procedure codes in combination with guidance codes for the same service. Do not unbundle PET/CT components; bill per bundled CPT guidance.

Do not pair a diagnostic code with a separate guidance code for the same procedural encounter
Do not unbundle PET/CT — bill per applicable bundled CPT listings

Billing Rule

Breast biopsy and MRI-guided breast biopsy coding

Breast biopsy coding: follow CPT guidance for core and image-guided biopsies; MRI-guided breast biopsy has specific codes and some guidance codes (e.g., 77021) are not appropriate for breast biopsy procedures.

Breast biopsy codes: 19085, 19086
Note: CPT 77021 is not appropriate for breast biopsy billing

Documentation Required

Physician supervision documentation for 3D rendering; document high-risk criteria and age

Document physician supervision and involvement when billing for 3D rendering. Record the supervising physician's engagement and medical necessity for the rendering service. Additionally, document high-risk criteria and patient age when relevant to support advanced imaging decisions.

Required documentation elements: supervising physician name and signature, description of physician involvement, indication for 3D rendering, date of service
High-risk documentation: family history details, known pathogenic variant (BRCA1/2 etc.), risk model score (e.g., Tyrer-Cuzick) or other validated risk tool, patient age
Do not pair 3D rendering with 3D mammography, MRI, or ultrasound — rendering is a separate post-processing service and must be billed accordingly

Billing Rule

Reporting Whole-Body MRI and PET-MRI when approved

Reporting Whole-Body MRI and PET-MRI: follow coding guidance for whole-body MRI and the appropriate pairing when PET-MRI is approved. Use CPT 76498 for whole-body MRI reporting where applicable and bill PET-MRI combinations per guidance when both PET and whole-body MRI components are performed.

Whole-body MRI: CPT 76498
PET-MRI when approved: bill 78813 in combination with 76498 per payer rules

Denial Risk

Limited CT misuse and routine implant surveillance (denial risks)

Limited CT misuse and routine implant surveillance are common denial risks. Avoid billing limited CT codes for studies that do not meet clinical indication requirements, and do not use advanced imaging for routine implant surveillance without documented clinical justification.

Limited CT misuse: ensure clinical indication supports limited CT rather than full diagnostic CT
Routine implant surveillance: generally a denial risk unless specific clinical concerns are documented

Documentation Required

Pregnant patient MRI contraindication and nipple discharge imaging pathway

Pregnant patient MRI contraindications and nipple discharge imaging pathway: document pregnancy status and follow contrast agent guidance; for nipple discharge, follow the specified imaging pathway and document steps taken. Avoid routine use of gadolinium-based contrast agents in pregnancy unless essential and justified; document informed consent and expected benefit.

Pregnancy: document pregnancy test results or last menstrual period; avoid MRI with GBCA in pregnancy unless benefit outweighs risk and is documented
Nipple discharge pathway: document clinical exam, cytology if performed, targeted imaging steps taken, and rationale for advanced imaging

Providers must verify and comply with state and contractual requirements for Ohio members and submit supporting documentation aligned with InterQual or other referenced clinical criteria to facilitate authorization and payment decisions.

Background, Evidence, and Definitions

Background: these UnitedHealthcare Community Plan guidelines are evidence-based, review advanced imaging modalities annually, and are grounded in national society guidance and peer-reviewed literature; they are intended to guide appropriate use, documentation, coding, and safety for NM, US, CT, MRI, and PET. The guidelines undergo formal annual review and are not intended to replace clinician judgment — physicians may override the guidance when clinically appropriate. The scope is limited to advanced imaging modalities relevant to breast imaging and related procedures, and applicability is limited to members in Ohio.

Evidence Item
FDA GBCA advisory: FDA notes gadolinium retention and recommends limiting GBCA use to circumstances where additional information is necessary (FDA May 16, 2018).
Sensitivity of contrast-enhanced MRI for invasive cancers and benign papillary lesions: reported 93–100%.
Whole-body MRI (WBMRI): feasibility demonstrated but lacks standardization and outcome data; not established as standard evaluation for cancers except select predisposition syndromes.
Incidental lesion malignancy on breast MRI: incidental lesions seen on ~15% of MRIs; malignancy rates vary 3%–20% depending on population; MRI identifies cancer in ~0.7% of 'inconclusive mammographic lesions'.
Malignancy rate in pathologic nipple discharge: estimated 11%–16%.
Radiation exposure: PEM (positron emission mammography) radiation dose reported ~23 times higher than digital mammography.
GBCA safety and MRI contrast guidance: multiple references note gadolinium deposition evidence but FDA states no proven harm while recommending limiting GBCA use and assessing need for repetitive GBCA exposures.

Quantitative MR Analysis (Preface-4.8) / 3D Rendering (BR-13.1)

3D rendering billing and usage prohibitions with breast imaging modalities.

3D Rendering (BR-13.1): CPT 76376 and 76377 should NOT be used with any 3D mammography code; are NOT indicated for breast ultrasound (including ABUS); and should NOT be used in conjunction with MRI Breast. Concurrent physician supervision documentation is required when these codes are used.

Providers may be required to obtain prior authorization for 3D codes even if not required for the underlying study.

Definitions:

- Concurrent supervision: active physician participation in and monitoring of 3D reconstruction and post-processing, including design of the anatomic region, determination of tissues/structures to display, images to archive, and monitoring/adjustment of the 3D work product.

- WBMRI (Whole-body MRI): whole-body MRI is reportable in this guideline using CPT 76498 and generally not supported except in select cancer predisposition syndromes and certain autoimmune conditions.

- BI-RADS: Breast Imaging Reporting and Data System categories used for lesion assessment and follow-up intervals (e.g., BI-RADS 3 follow-up at 6, 12, 18, 24 months).

- Pathologic nipple discharge: unilateral, bloody or serous, arising from a single duct, persistent, and spontaneous (distinguished from physiologic discharge which is often bilateral and milky/non-bloody).

- InterQual: the primary medical/surgical criteria system used by UnitedHealthcare for utilization decisions; other UHC policies/guidelines may be used if InterQual is not applicable.

Revision History

02/01/2024revised

Annual evidence-based updates.

07/01/2024revised

Interim evidence-based updates and minor editorial updates.

05/01/2025revisedLatest

Annual evidence-based updates.