Breast Imaging Guidelines

Breast imaging services—including screening and diagnostic mammography, breast ultrasound, and advanced imaging such as breast MRI—are covered and managed using BI‑RADS categorizations to guide follow‑up and interventions. The policy applies to individuals with common breast symptoms and for routine screening, with BI‑RADS examples (Category 0: additional specified imaging; Category 3: short‑interval follow‑up; Category 4: consider biopsy) and supplemental ultrasound limited to high‑risk women with dense breasts when MRI cannot be performed. Advanced/diagnostic imaging generally requires a current clinical evaluation since onset or change in symptoms (screening is exempt), completion of appropriate non‑advanced imaging and labs where applicable, and physician review for atypical presentations; routine stand‑alone or combined ultrasound screening is not medically necessary.

"This tool addresses common symptoms and symptom complexes."