MRI (Magnetic Resonance Imaging) of the Breast Form

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MRI (Magnetic Resonance Imaging) of the Breast Medical Guideline

Service: MRI Breast

PUM 250-0051-1812

Medical Guideline Committee Approval Q1 2026 Effective Date 05/01/2026

Description: Magnetic Resonance Imaging (MRI) of the breast is commonly used in conjunction with mammography and/or ultrasound but may also be used as a “stand- alone” imaging technique of the breasts. It is mostly used in the screening, diagnosis, or characterization of breast cancer.

Indications of Coverage:

MRI of the Breast is considered medically necessary when at least ONE of the following criteria are met:

I. Known Breast Cancer and at least ONE of the following:

A. Evaluation of invasive breast cancer (ductal or lobular):

• for initial staging when mammography/ultrasound is indeterminate in defining the extent of cancer, OR
• whether the tumor is multifocal/multicentric, OR
• with size discrepancy between tumor size on imaging versus physical exam • To evaluate for residual cancer after recent breast surgery with positive tumor margins on lumpectomy, and repeat excision is planned, with the patient requesting breast conservation.

B. Presurgical localization is needed.

C. Evaluation of tumor after neoadjuvant (preoperative) chemotherapy for planning of breast conserving surgery.

D. Evaluation of tumor prior to neoadjuvant chemotherapy to serve as a baseline.

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E. With newly diagnosed breast cancer and need to evaluate the contralateral breast, provided contralateral breast mammography is either negative or indeterminate.

F. For staging of disease with high risk or suspicion of occult disease (such as ER/PR neg and Her2neu neg tumor, or with underlying BRCA mutation).

G. Post Biopsy Imaging: For lesions initially seen on MRI Breast and that have benign and non-specific, equivocal or uncertain histology (based on a stereotactic, MRI-guided, or US-directed breast biopsy), an MRI Breast can be repeated at least 6 months after the biopsy to document successful lesion sampling.

H. For breast cancer diagnosed before age 50 is eligible for annual breast MRI.

I. For more thorough evaluation of biopsy proven atypical ductal hyperplasia, OR lobular neoplasia (lobular carcinoma in situ, OR atypical lobular hyperplasia), when extent of disease is not adequately defined by mammography, ultrasound or physical exam.

J. To evaluate extent of disease after biopsy-proven Paget’s disease of nipple/areola.

K. Post surgical follow-up AND either:

• suspected tumor recurrence at lumpectomy site, provided mammogram is negative or indeterminate, OR
• with positive or close surgical margins after lumpectomy, to assess for residual disease, OR
• screening in the contralateral breast in patient with BRCA mutation.

II. Further Evaluation of Breast abnormality, when at least ONE of the following are met:

A. Breast lesion is ALL of the following:

• nonpalpable
• equivocal on mammography

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• not visible on ultrasound (or ultrasound indeterminate)
• not amenable to mammographic, stereotactic, or ultrasound guided fine needle biopsy.

B. Breast lesion for which anatomic guidance is needed for biopsy, with mammographic and ultrasound findings indeterminate or equivocal.

C. In a patient with asymptomatic silicone breast implants, to evaluate for leak or rupture of implant, or complication of implant, ONLY if mammography and/or ultrasound results are either abnormal or indeterminate regarding implant integrity. (Provided the implants were not placed as part of a purely cosmetic surgery, in which case health plan certificate language may not provide coverage.) **

D. In a patient with symptomatic silicone breast implants, MRI is medically necessary, and a preceding mammogram or ultrasound is not required. (Provided the implants were not placed as part of a purely cosmetic surgery, in which case health plan certificate language may not provide coverage.) **

E. New nipple inversion or skin changes suspicious for inflammatory breast cancer or unilateral bloody or serous nipple discharge, with inconclusive mammography and ultrasound.

F. With negative/indeterminate mammography, with no palpable mass, but suspected Paget Disease, with either bleeding, eczema, itching, or ulcer of the nipple or areola.

G. Suspicious mass or breast distortion/abnormality in a patient with history of breast cancer, and other imaging is indeterminate.

H. For biopsy proven phylloides tumor, to determine extent of disease and for preoperative planning.

I. A probably benign lesion on MRI (MRI BI-RADS 3) should undergo repeat MRI in 6 months. If repeat imaging remains MRI BI-RADS 3, then repeat at 12 months, 18 months and 24 months from the date of the initial imaging. After 2 years of stability, the findings should be assessed as benign (Category 2). If repeat imaging is BI-RADS 1 or 2, then imaging reverts to routine per patient’s risk profile.

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III. For Breast Cancer Screening* with no personal history of breast or ovarian cancer and at least ONE of the following A.—E.:

A. Personal history of mutation in one of the high-risk breast cancer genes (specifically, BRCA1, BRCA2, TP53, PTEN, ATM, BARD1, CDH1, CHEK2, NBN, NF1, PALB2, STK11, RAD51C, RAD51D).

B. Lifetime risk of breast cancer of at least 20%, based on validated risk assessment models, such as Gail (Breast Cancer Risk Assessment Tool), Claus, Tyrer-Cuzick, or BRCAPRO.

C. Personal history of chest irradiation between the ages 10 and 30 years old.

D. Inconclusive screening mammogram (Category 0) due to extremely dense breast tissue or tissue obscuration from implants.

E. Personal history of ONE of the following syndromes:

• Peutz-Jeghers
• Li-Fraumeni
• Cowden syndrome
• Bannayan-Riley-Ruvalcaba syndrome

• Hereditary diffuse gastric cancer with CDH1 mutation
• History of lobular carcinoma in situ (LCIS) or atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH).

IV.
Family history of ONE of the following:

A. No prior personal genetic testing, but parent, sibling or child with documented BRCA1 or BRCA2 mutation.

B. Breast cancer in a male relative

C. Parent, sibling or child with ONE of the following syndromes:

• Peutz-Jeghers
• Li-Fraumeni
• Cowden syndrome

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• Bannayan-Riley-Ruvalcaba syndrome
• Hereditary diffuse gastric cancer with CDH1 mutation

V.
For Breast Cancer Annual Screening with a personal history of Breast

cancer and ANY of the following:

A. breast cancer diagnosed at or before age 50.

B. breast density Category D.

C. personal history of mutation in high-risk breast cancer genes (BRCA1, BRCA2, TP53, PTEN, ATM, BARD1, CDH1, CHEK2, NF1, PALB2, STK11, RAD51C, RAD51D).

D. primary breast cancer which had been mammographically occult (not detected on earlier mammography).

VI. To evaluate for occult breast cancer with biopsy proven adenocarcinoma, no

known primary, with ALL of the following:

A. negative mammography

B. negative breast ultrasound

C. no palpable breast lumps (for example, biopsy proven axillary node adenocarcinoma but no known breast primary tumor).

VII. Repeat Breast MRI, after completing MR of the same anatomic site in the past 6 months, will be reviewed on a case-by-case basis. The most recent imaging reports must be submitted, and for the repeat exam to be approved as medically necessary, ONE of the following MUST be met:

a) documentation that the prior testing was inconclusive, or with short-term follow-up imaging recommended. b) clinical documentation of progressive worsening of symptoms or new physical exam findings prompting the repeat imaging, and that patient management will be altered by the imaging results.
c) interval surgery (with suspected complication) or significant new trauma to that anatomic region.

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*Guidelines for periodic repeat high risk screening testing:

A. With lifetime breast cancer risk at least 20%, based on validated risk assessment models, such as Gail (Breast Cancer Risk Assessment Tool), Claus, Tyrer-Cuzick, or BRCAPRO, annual MRI is considered medically necessary at age 40, or ten years prior to the youngest family member age at breast cancer diagnosis, but not before age 25.

B. With personal history of atypical ductal hyperplasia or lobular neoplasia (lobular carcinoma in situ/atypical lobular hyperplasia), annual MRI is considered medically necessary from the time of diagnosis, but not before the age of 25.

C. With personal history of previous chest irradiation between ages 10 and 30, annual MRI is considered medically necessary after age 25 and at least 8 years after completion of radiation.

D. With known personal history of BRCA1 or BRCA2 mutation, or with no personal prior BRCA testing, but with known BRCA mutation in sibling, parent or children, annual MRI after age 25 is considered medically necessary.

E. With personal history of breast cancer linked genes, annual MRI is considered medically necessary for ANY of the following:

• beginning at age 30 for mutations in CDH1, CHEK2, PALB2, ATM, NF1 (ending at age 50 for NF1), STK11 (Peutz-Jeghers).
• beginning at age 40 for RAD51C, RAD51D, BARD1
• for TP53 (Li-Fraumeni), beginning at age 20 or at age of earliest familial breast cancer, if that was less than 20.
• for Cowden syndrome or Bannayan-Riley-Ruvalcaba, beginning at age 35, or ten years prior to the age of earliest breast cancer diagnosis in the family.

F. With a personal history of breast cancer and at least ONE of the criteria under V. A.-D. above, annual surveillance/screening MRI is considered medically necessary.

**Prior to any approval of Breast MRI for silicone implants, check member certificate for potential general exclusion for services related to a noncovered

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service. If the implants were placed for cosmetic purposes (and not breast cancer related), then complications of those implants, and imaging of those complications, may not be a covered benefit.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.” A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. Breast MRI for cancer screening before the age of 25 is considered not medically necessary.

E. Breast MRI for evaluation of suspected complications of saline breast implants is considered not medically necessary.

F. Breast MRI for the evaluation of asymptomatic silicone implants is considered not medically necessary, unless either mammography or ultrasound results are either abnormal or indeterminate regarding implant integrity.

G. Screening/Surveillance Breast MRI more frequent than every 12 months is considered not medically necessary.

H. More than one follow-up breast MRI for reevaluation of a previously indeterminate MRI finding is considered not medically necessary unless the latest Breast MRI showed an interval change or was interpreted as highly suspicious.

Documentation Required:

Prior authorization is required for all breast MRI procedures. To obtain prior authorization, the requesting provider must submit the following information:

• A standard written order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.

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• Medical record information (including continued need/use if applicable) and medical necessity. • Correct coding for the service that meets all coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.
Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered. State mandates, laws or benchmark supersede this medical guideline.

Imaging is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

**All imaging related to cancer care, WPS uses NCCN as a primary reference.

Guideline Review History:

Implemented 01/01/24, 08/01/24, 09/01/25, 05/01/26 Medical Guideline Committee Approval 10/26/23, 07/25/24, 03/27/25, Q1 2026 Reviewed

10/26/23, 07/25/24, 03/27/25, Q1 2026 Revised 02/23/24 effective 04/23/24 Developed 10/26/23

Approved by the Medical Director

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Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Codes
Code Description

PRIMARY PROCEDURE CODES 77046 Magnetic resonance imaging, breast, without contrast material; unilateral
77047 Magnetic resonance imaging, breast, without contrast material; bilateral
77048 Magnetic resonance imaging, breast without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed unilateral
77049 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral
C8903 Magnetic resonance imaging with contrast, breast; unilateral
C8905 Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral
C8906 Magnetic resonance imaging with contrast, breast; bilateral
C8908 Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral
C8937 Computer-aided detection, including computer algorithm analysis of breast MRI image data for lesion destruction/characterization, pharmacokinetic analysis, with further physician review for interpretation (list separately in addition to code for primary procedure)
0907T Ablation, benign breast tumor (e.g., fibroadenoma), percutaneous, laser, including imaging guidance with performed, each tumor
0971T Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral

ASSOCIATED CODES A9573 Injection, Gadopiclenol, 1 ml
A9575 Injection, Gadoterate Meglumine, 0.1 ml
A9577 Injection, Gadobenate Dimeglumine (Multihance), per ml
A9579 Injection, Gadolinium-based magnetic resonance contrast agent, not otherwise specified (NOS), per ml
A9585 Injection, Gadobutrol, 0.1 ml

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