Breast Imaging Guidelines

This policy covers breast imaging services including screening mammography, breast ultrasound, breast MRI (bilateral with and without contrast), 3D rendering, reconstruction-related imaging, and evaluation for nipple discharge, mastodynia, suspected male breast cancer, pregnant/lactating and transgender patients, and individuals with breast implants. Major limitations/requirements: advanced imaging generally requires a current clinical evaluation (history/physical and appropriate prior studies such as mammogram/ultrasound) except for screening, MRI is authorized only when indicated and only with specified codes (CPT 77049, HCPCS C8908, and CPT 77047 where noted), atypical presentations require physician review, and Category 0 findings mandate additional specified imaging for completion.

"History of lobular carcinoma in situ (LCIS) — MRI screening to begin at diagnosis but not prior to age 25."