76498
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the guidelines titled Medical Records Documentation Used for Reviews.
- When deciding coverage, reference the member specific benefit plan document and any applicable federal or state mandates; in the event of a conflict, the member specific benefit plan document governs.
- Coding clarification relevant to billing: Computer-aided detection (CAD) is included with the MRI breast CPT code 77048 and 77049 procedures. If CAD is performed with these codes, there is no additional reimbursement.
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
Key Coverage Criteria
- Magnetic Resonance Imaging (MRI) of the breast for individuals who are high risk for breast cancer as defined as having any of the following:
- Prior thoracic radiation therapy between the ages 10 and 30 (screening starting at age 25 or 8 years after treatment, whichever is later)
- Lifetime risk estimated at greater than or equal to 20% as defined by models that are largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick or BRCAPRO)
- Personal history of breast cancer (not treated with bilateral mastectomy)
- Personal history with any of the following gene mutations/conditions: ATM (screening beginning at age 30)
- Personal history with any of the following gene mutations/conditions: BARD1 (screening beginning at age 40)
17 Active Policies
UHC-POL-gastrointestinal-motility-disorders-diagnosis-treatment — Gastrointestinal Disorders Diagnostic Procedures
UHC-POL-mri-ct-scan-site-of-service — Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scan – Site of Service
UMR-POL-UMR-breast-imaging-screening-diagnosing-cancer — Breast Imaging for Screening and Diagnosing Cancer
UMR-POL-UMR-gastrointestinal-motility-disorders-diagnosis-treatment — Gastrointestinal Disorders Diagnostic Procedures
Related Codes
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