Breast Imaging Guidelines

This policy covers breast imaging services—including mammography, breast ultrasound, breast MRI (with specified CPT/HCPCS codes), 3D rendering and reconstruction-related imaging—for symptomatic breast complaints (e.g., nipple discharge, mastodynia), evaluation in pregnant/lactating patients, suspected male breast cancer, and supplemental screening for high‑risk or transgender individuals. Major limitations: advanced/diagnostic imaging generally requires a current clinical evaluation since onset/change in symptoms (screening MRI does not), MRI is not indicated in certain scenarios, only the listed MRI codes are supported (for implants only CPT 77047 without contrast), routine stand‑alone screening ultrasound is inappropriate, and atypical presentations require physician review.

"Note: "Current clinical evaluation is not required prior to screening studies."

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