Criteria
Coverage is subject to the specific terms of the member's benefit plan.
MRI of the breast may be considered medically necessary for individuals with silicone implants when EITHER of the following are met:
- Confirmation of silicone gel-filled breast implant ruptures, when this diagnosis cannot be confirmed by mammography or breast ultrasound; or
- For postoperative evaluation of silicone breast implant complications.
MRI of the breast may be considered medically necessary for individuals with no history of known breast cancer
- For screening examination to detect breast cancer in ANY of the following situations:
- Inconclusive screening mammogram due to breast characteristics limiting the sensitivity of mammography (e.g., extremely or heterogeneously dense breasts, implants); or
- A breast cancer risk assessment (by the Gail risk or other validated breast cancer risk assessment models) that identifies the individual as having a lifetime risk of 20% or greater of developing breast cancer (approve annually); or
- Two (2) or more first degree relatives (parents, siblings, and children) have history of breast cancer; or
- Individuals with histories of extensive chest irradiation (usually as treatment for Hodgkin's or other lymphoma.) Approve annually starting at age 30; or
- Individuals with known BRCA mutation. Approve annually starting at age 30; or
- Individuals not yet tested for BRCA gene, but with known BRCA mutation in first degree relative. Approve annually starting at age 30.
- For evaluation of identified lesion, mass or abnormality in breast in ANY of the following situations:
- Two (2) or more first degree relatives (parents, siblings, and children) have history of breast cancer; or
- Evaluation of suspected breast cancer when other imaging examinations, such as ultrasound and mammography, and physical examination are inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g. seen only in single view mammogram without ultrasound correlation); or
- Previous positive breast biopsy within the previous four (4) months and no intervening previous breast MRI; or
- Inconclusive screening mammogram due to breast characteristics limiting the sensitivity of mammography (e.g., extremely or heterogeneously dense breasts, implants); or
- Evaluation of palpable lesion on physical examination and not visualized on ultrasound or mammogram and MRI guided biopsy considered; or
- For evaluation of axillary node metastasis or adenocarcinoma with normal physical examination and normal breast mammogram; or
- Individuals diagnosed with biopsy-proven lobular neoplasia or atypical ductal hyperplasia (ADH); or
- Personal history of or first-degree relative with Le-Fraumeni syndrome (TP53 mutation), Cowden syndrome (PTEN) or Bannayan-RileyRuvalcaba syndrome (BRRS).
MRI of the breast may be considered medically necessary for individuals with history of known breast cancer
- For screening examination to detect breast cancer in ANY of the following situations:
- Individuals with a known history of Breast Cancer: Approve initial staging, with treatment [within three (3) months], and yearly surveillance for detection of recurrence or a new cancer.
- For evaluation of identified lesion, mass or abnormality in breast in ANY of the following situations:
- For evaluation of breast lesion, identifying whether single or multi-focal, in individual with diagnosed breast cancer; or
- For evaluation of suspicious mass, lesion, distortion or abnormality of breast in individual with history of breast cancer.
- Pre-operative:
- For preoperative evaluation for known breast cancer when surgery planned within thirty (30) days; or
- Evaluation of more than two (2) lesions to optimize surgical planning when requested by surgeon or primary care provider on behalf of surgeon who has seen the individual.
A follow-up study may be considered medically necessary to help evaluate an individual's progress after treatment, procedure, intervention or surgery.
Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.
Procedure Codes
