Aetna · Clinical coverage policy

Aetna Breast MRI coverage criteria

Aetna covers breast MRI as medically necessary in defined situations: as a diagnostic/management adjunct when the member has had a recent (within 1 year) mammogram and/or breast ultrasound (e.g., prior chest radiation at ages 10-30, neoadjuvant chemo planning, implant rupture in symptomatic members, occult/recurrent or multicentric/lobular/Paget cancer work-up, inconclusive imaging); as a screening adjunct to mammography for women at high genetic risk (defined mutations and lifetime risk 20-25%+, with mutation-specific start ages); and for silent silicone implant rupture, phyllodes tumor, newly diagnosed Paget disease, and BI-RADS 3 MRI lesion follow-up. The key gate is that breast MRI must fit one of the listed indications; screening MRI generally requires high genetic risk plus a mammogram within the past year. Many other uses (e.g., average-risk screening, BI-RADS 4/5 lesion characterization, LCIS/DCIS/ADH evaluation, screening BRCA-positive men) are deemed experimental/investigational, and certain frequency limits apply.

Policy CPB 0105 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0105

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0105 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Breast MRI (CPT 77046), and what gets it denied?

Path
Aetna covers breast MRI as medically necessary in defined situations: as a diagnostic/management adjunct when the member has had a recent (within 1 year) mammogram and/or breast ultrasound (e.g., prior chest radiation at ages 10-30, neoadjuvant chemo planning, implant rupture in symptomatic members, occult/recurrent or multicentric/lobular/Paget cancer work-up, inconclusive imaging); as a screening adjunct to mammography for women at high genetic risk (defined mutations and lifetime risk 20-25%+, with mutation-specific start ages); and for silent silicone implant rupture, phyllodes tumor, newly diagnosed Paget disease, and BI-RADS 3 MRI lesion follow-up. The key gate is that breast MRI must fit one of the listed indications; screening MRI generally requires high genetic risk plus a mammogram within the past year. Many other uses (e.g., average-risk screening, BI-RADS 4/5 lesion characterization, LCIS/DCIS/ADH evaluation, screening BRCA-positive men) are deemed experimental/investigational, and certain frequency limits apply. Coverage criteria include: Lead-in: Aetna considers MRI of the breast medically necessary for ANY of the following (Categories 1-6 below).; CATEGORY 1 (with or without contrast, member must have a recent conventional mammogram and/or breast sonogram within the past year, in ANY of the following circumstances where MRI may affect clinical management): For individuals who received radiation treatment to the chest between ages 10-30 years (e.g., Hodgkin disease, Wilms tumors).; CATEGORY 1: To assess tumor location, size, and extent before and/or after neoadjuvant chemotherapy in persons with locally advanced breast cancer, for determination of eligibility for breast conservation therapy.; CATEGORY 1: To detect implant rupture in symptomatic members.; CATEGORY 1: To detect suspected local tumor recurrence in members with breast cancer who have undergone mastectomy and breast reconstruction with an implant.; CATEGORY 1: To detect local tumor recurrence in individuals with breast cancer who have radiographically dense breasts OR old scar tissue from previous breast surgery that compromises the ability of combined mammography and ultrasonography.; CATEGORY 1: To detect the extent of residual cancer in the recently post-operative breast with positive pathological margins after incomplete lumpectomy, when the member still desires breast conservation and local re-excision is planned.; CATEGORY 1: To guide localization of breast lesions to perform needle biopsy when suspicious lesions exclusively detected by contrast-enhanced MRI cannot be visualized with mammography or ultrasonography.; CATEGORY 1: To localize the site of primary occult breast cancer in individuals with adenocarcinoma suggestive of breast cancer discovered as axillary node metastasis or distant metastasis, without focal findings on physical examination or on mammography/ultrasonography.; CATEGORY 1: To map the extent of primary tumors and identify multi-centric disease in persons with ANY of the following: multifocal or multicentric breast cancer; before neoadjuvant systemic therapy; adenocarcinoma in axillary lymph node without a breast primary site identified on mammogram/ultrasound; invasive lobular carcinoma; OR Paget's disease of the breast.; CATEGORY 1: Contralateral breast examination for members with ANY of the following: multifocal or multicentric breast cancer; before neoadjuvant systemic therapy; adenocarcinoma in axillary lymph node without a breast primary site identified on mammogram/ultrasound; invasive lobular carcinoma; OR Paget's disease of the breast.; CATEGORY 1: Lesion characterization (nipple retraction, unilateral drainage from the nipple that is bloody or clear) when all other imaging examinations such as ultrasound and mammography, and physical examination, are inconclusive for the presence of breast cancer.; CATEGORY 1: After breast conservation therapy in women who exhibit suspicious clinical or imaging findings that remain indeterminate after complete mammographic and sonographic evaluations.; CATEGORY 1: Evaluation of inconclusive or conflicting findings on mammography or ultrasound that is NOT a discrete palpable mass.; CATEGORY 2 (as an adjunct to mammography for screening of women considered to be at high genetic risk of breast cancer because of ANY of the following; mammography must have been performed within the past year; mammography NOT required for women under age 30 years): Carry or have a first-degree relative who carries a genetic mutation in the PTEN gene (Cowden and Bannayan-Riley-Ruvalcaba syndromes) — screening beginning at age 30 for PTEN.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in the TP53 gene (Li-Fraumeni syndrome) — screening beginning at age 20 years OR age of earliest diagnosed breast cancer in the family for TP53.; CATEGORY 2 (high genetic risk screening): Carry a PALB2 mutation — beginning at age 30.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in Peutz-Jeghers syndrome (STK11/LKB1 gene variations) — beginning at age 30 years.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in CDH1 or NF1 — beginning at age 30.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in ATM, CHEK2, or NBN — beginning at age 40.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in BARD1, RAD51C, or RAD51D — beginning at age 40.; CATEGORY 2 (high genetic risk screening): Confirmed presence of BRCA1 or BRCA2 mutation — beginning at age 25 years.; CATEGORY 2 (high genetic risk screening): First-degree blood relative with BRCA1 or BRCA2 mutation and are untested.; CATEGORY 2 (high genetic risk screening): Have a lifetime risk of breast cancer of 20 to 25% or more using standard risk assessment models (BRCAPRO, Claus model, Gail model, or Tyrer-Cuzick).; CATEGORY 3: To detect intra-capsular (silent) rupture of silicone gel-filled breast implants. NOTE: screening for silent intra-capsular rupture more frequently than every 2 years is NOT considered medically necessary.; CATEGORY 4: Phyllodes tumor (cystosarcoma phyllodes) — indicated preoperatively to establish extent of disease, where diagnosis has been established by biopsy.; CATEGORY 5: Newly diagnosed Paget's disease.; CATEGORY 6: To follow-up a probable benign lesion on MRI (BI-RADS 3 lesions) that was originally detected by MRI — follow-up MRI of BI-RADS 3 lesions is considered medically necessary every 6 months for up to 2 years; if repeat imaging is BI-RADS 1 or 2, then imaging reverts to routine per individual's risk profile. (MRI is NOT considered medically necessary for the initial evaluation of BI-RADS 3 lesions.). Applies to 8 codes: 77046, 77047, 77048, 77049, 19085, 19086, 19287, 19288.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Lead-in: The following breast MRI indications are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established (not an all-inclusive list).; Experimental/investigational: Dermatomyositis as an indication for use of MRI for breast cancer screening.; Experimental/investigational: Follow-up/surveillance of Paget's disease.; Experimental/investigational: Quantitative measurements of breast density.; Experimental/investigational: Screening of persons with APC or GALNT12 mutations.; Experimental/investigational: Surveillance of asymptomatic individuals with breast cancer or carcinoma in situ who have completed primary therapy and who are not at high genetic risk of breast cancer.; Experimental/investigational: To confirm implant rupture in symptomatic individuals whose ultrasonography shows rupture, especially with implants more than 10 years old (ultrasound is sufficient to proceed with removal).; Experimental/investigational: To diagnose fat necrosis post-breast reduction surgery.; Experimental/investigational: To differentiate benign from malignant breast disease, especially clustered micro-calcifications.; Experimental/investigational: To differentiate cysts from solid lesions (ultrasound indicated).; Experimental/investigational: To evaluate breasts before biopsy in an effort to reduce the number of surgical biopsies for benign lesions.; Experimental/investigational: To evaluate suspicious (BI-RADS 4 or 5) lesions found on mammogram and/or ultrasound (a lesion categorized as BI-RADS 4 or 5 should be biopsied).; Experimental/investigational: To evaluate persons with lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), or atypical ductal hyperplasia (ADH).; Experimental/investigational: To evaluate retro-pectoral fat grafting in breast reduction.; Experimental/investigational: To provide an early prediction of response to adjuvant breast cancer chemotherapy in guiding choice of chemotherapy regimen.; Experimental/investigational: To screen for breast cancer in members with average risk of breast cancer.; Experimental/investigational: To screen BRCA-positive men.; Experimental/investigational: To screen individuals with MUTYH mutation.; Experimental/investigational: Women with dense breasts and/or fibrocystic breast disease who are asymptomatic and have no additional risk factors.; Experimental/investigational: Post-surgical intra-operative breast MRI for quantifying tumor deformation and detecting residual breast cancer.; Experimental/investigational: Quantitative breast MRI for predicting the risk of breast cancer recurrence.; Not medically necessary (frequency limit): Screening for silent intra-capsular rupture of silicone gel-filled breast implants more frequently than every 2 years is not considered medically necessary.; Not medically necessary: MRI is not considered medically necessary for the initial evaluation of BI-RADS 3 lesions.; Not separately reimbursed: Aetna considers computer-aided detection of malignancy integral to MRI of the breast and not separately reimbursed. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0105 — Breast MRI

Coverage criteria

  • Lead-in: Aetna considers MRI of the breast medically necessary for ANY of the following (Categories 1-6 below).
  • CATEGORY 1 (with or without contrast, member must have a recent conventional mammogram and/or breast sonogram within the past year, in ANY of the following circumstances where MRI may affect clinical management): For individuals who received radiation treatment to the chest between ages 10-30 years (e.g., Hodgkin disease, Wilms tumors).
  • CATEGORY 1: To assess tumor location, size, and extent before and/or after neoadjuvant chemotherapy in persons with locally advanced breast cancer, for determination of eligibility for breast conservation therapy.
  • CATEGORY 1: To detect implant rupture in symptomatic members.
  • CATEGORY 1: To detect suspected local tumor recurrence in members with breast cancer who have undergone mastectomy and breast reconstruction with an implant.
  • CATEGORY 1: To detect local tumor recurrence in individuals with breast cancer who have radiographically dense breasts OR old scar tissue from previous breast surgery that compromises the ability of combined mammography and ultrasonography.
  • CATEGORY 1: To detect the extent of residual cancer in the recently post-operative breast with positive pathological margins after incomplete lumpectomy, when the member still desires breast conservation and local re-excision is planned.
  • CATEGORY 1: To guide localization of breast lesions to perform needle biopsy when suspicious lesions exclusively detected by contrast-enhanced MRI cannot be visualized with mammography or ultrasonography.
  • CATEGORY 1: To localize the site of primary occult breast cancer in individuals with adenocarcinoma suggestive of breast cancer discovered as axillary node metastasis or distant metastasis, without focal findings on physical examination or on mammography/ultrasonography.
  • CATEGORY 1: To map the extent of primary tumors and identify multi-centric disease in persons with ANY of the following: multifocal or multicentric breast cancer; before neoadjuvant systemic therapy; adenocarcinoma in axillary lymph node without a breast primary site identified on mammogram/ultrasound; invasive lobular carcinoma; OR Paget's disease of the breast.
  • CATEGORY 1: Contralateral breast examination for members with ANY of the following: multifocal or multicentric breast cancer; before neoadjuvant systemic therapy; adenocarcinoma in axillary lymph node without a breast primary site identified on mammogram/ultrasound; invasive lobular carcinoma; OR Paget's disease of the breast.
  • CATEGORY 1: Lesion characterization (nipple retraction, unilateral drainage from the nipple that is bloody or clear) when all other imaging examinations such as ultrasound and mammography, and physical examination, are inconclusive for the presence of breast cancer.
  • CATEGORY 1: After breast conservation therapy in women who exhibit suspicious clinical or imaging findings that remain indeterminate after complete mammographic and sonographic evaluations.
  • CATEGORY 1: Evaluation of inconclusive or conflicting findings on mammography or ultrasound that is NOT a discrete palpable mass.
  • CATEGORY 2 (as an adjunct to mammography for screening of women considered to be at high genetic risk of breast cancer because of ANY of the following; mammography must have been performed within the past year; mammography NOT required for women under age 30 years): Carry or have a first-degree relative who carries a genetic mutation in the PTEN gene (Cowden and Bannayan-Riley-Ruvalcaba syndromes) — screening beginning at age 30 for PTEN.
  • CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in the TP53 gene (Li-Fraumeni syndrome) — screening beginning at age 20 years OR age of earliest diagnosed breast cancer in the family for TP53.
  • CATEGORY 2 (high genetic risk screening): Carry a PALB2 mutation — beginning at age 30.
  • CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in Peutz-Jeghers syndrome (STK11/LKB1 gene variations) — beginning at age 30 years.
  • CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in CDH1 or NF1 — beginning at age 30.
  • CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in ATM, CHEK2, or NBN — beginning at age 40.
  • CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in BARD1, RAD51C, or RAD51D — beginning at age 40.
  • CATEGORY 2 (high genetic risk screening): Confirmed presence of BRCA1 or BRCA2 mutation — beginning at age 25 years.
  • CATEGORY 2 (high genetic risk screening): First-degree blood relative with BRCA1 or BRCA2 mutation and are untested.
  • CATEGORY 2 (high genetic risk screening): Have a lifetime risk of breast cancer of 20 to 25% or more using standard risk assessment models (BRCAPRO, Claus model, Gail model, or Tyrer-Cuzick).
  • CATEGORY 3: To detect intra-capsular (silent) rupture of silicone gel-filled breast implants. NOTE: screening for silent intra-capsular rupture more frequently than every 2 years is NOT considered medically necessary.
  • CATEGORY 4: Phyllodes tumor (cystosarcoma phyllodes) — indicated preoperatively to establish extent of disease, where diagnosis has been established by biopsy.
  • CATEGORY 5: Newly diagnosed Paget's disease.
  • CATEGORY 6: To follow-up a probable benign lesion on MRI (BI-RADS 3 lesions) that was originally detected by MRI — follow-up MRI of BI-RADS 3 lesions is considered medically necessary every 6 months for up to 2 years; if repeat imaging is BI-RADS 1 or 2, then imaging reverts to routine per individual's risk profile. (MRI is NOT considered medically necessary for the initial evaluation of BI-RADS 3 lesions.)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Breast MRI (CPT 77046), and what gets it denied?
Aetna covers breast MRI as medically necessary in defined situations: as a diagnostic/management adjunct when the member has had a recent (within 1 year) mammogram and/or breast ultrasound (e.g., prior chest radiation at ages 10-30, neoadjuvant chemo planning, implant rupture in symptomatic members, occult/recurrent or multicentric/lobular/Paget cancer work-up, inconclusive imaging); as a screening adjunct to mammography for women at high genetic risk (defined mutations and lifetime risk 20-25%+, with mutation-specific start ages); and for silent silicone implant rupture, phyllodes tumor, newly diagnosed Paget disease, and BI-RADS 3 MRI lesion follow-up. The key gate is that breast MRI must fit one of the listed indications; screening MRI generally requires high genetic risk plus a mammogram within the past year. Many other uses (e.g., average-risk screening, BI-RADS 4/5 lesion characterization, LCIS/DCIS/ADH evaluation, screening BRCA-positive men) are deemed experimental/investigational, and certain frequency limits apply. Coverage criteria include: Lead-in: Aetna considers MRI of the breast medically necessary for ANY of the following (Categories 1-6 below).; CATEGORY 1 (with or without contrast, member must have a recent conventional mammogram and/or breast sonogram within the past year, in ANY of the following circumstances where MRI may affect clinical management): For individuals who received radiation treatment to the chest between ages 10-30 years (e.g., Hodgkin disease, Wilms tumors).; CATEGORY 1: To assess tumor location, size, and extent before and/or after neoadjuvant chemotherapy in persons with locally advanced breast cancer, for determination of eligibility for breast conservation therapy.; CATEGORY 1: To detect implant rupture in symptomatic members.; CATEGORY 1: To detect suspected local tumor recurrence in members with breast cancer who have undergone mastectomy and breast reconstruction with an implant.; CATEGORY 1: To detect local tumor recurrence in individuals with breast cancer who have radiographically dense breasts OR old scar tissue from previous breast surgery that compromises the ability of combined mammography and ultrasonography.; CATEGORY 1: To detect the extent of residual cancer in the recently post-operative breast with positive pathological margins after incomplete lumpectomy, when the member still desires breast conservation and local re-excision is planned.; CATEGORY 1: To guide localization of breast lesions to perform needle biopsy when suspicious lesions exclusively detected by contrast-enhanced MRI cannot be visualized with mammography or ultrasonography.; CATEGORY 1: To localize the site of primary occult breast cancer in individuals with adenocarcinoma suggestive of breast cancer discovered as axillary node metastasis or distant metastasis, without focal findings on physical examination or on mammography/ultrasonography.; CATEGORY 1: To map the extent of primary tumors and identify multi-centric disease in persons with ANY of the following: multifocal or multicentric breast cancer; before neoadjuvant systemic therapy; adenocarcinoma in axillary lymph node without a breast primary site identified on mammogram/ultrasound; invasive lobular carcinoma; OR Paget's disease of the breast.; CATEGORY 1: Contralateral breast examination for members with ANY of the following: multifocal or multicentric breast cancer; before neoadjuvant systemic therapy; adenocarcinoma in axillary lymph node without a breast primary site identified on mammogram/ultrasound; invasive lobular carcinoma; OR Paget's disease of the breast.; CATEGORY 1: Lesion characterization (nipple retraction, unilateral drainage from the nipple that is bloody or clear) when all other imaging examinations such as ultrasound and mammography, and physical examination, are inconclusive for the presence of breast cancer.; CATEGORY 1: After breast conservation therapy in women who exhibit suspicious clinical or imaging findings that remain indeterminate after complete mammographic and sonographic evaluations.; CATEGORY 1: Evaluation of inconclusive or conflicting findings on mammography or ultrasound that is NOT a discrete palpable mass.; CATEGORY 2 (as an adjunct to mammography for screening of women considered to be at high genetic risk of breast cancer because of ANY of the following; mammography must have been performed within the past year; mammography NOT required for women under age 30 years): Carry or have a first-degree relative who carries a genetic mutation in the PTEN gene (Cowden and Bannayan-Riley-Ruvalcaba syndromes) — screening beginning at age 30 for PTEN.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in the TP53 gene (Li-Fraumeni syndrome) — screening beginning at age 20 years OR age of earliest diagnosed breast cancer in the family for TP53.; CATEGORY 2 (high genetic risk screening): Carry a PALB2 mutation — beginning at age 30.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in Peutz-Jeghers syndrome (STK11/LKB1 gene variations) — beginning at age 30 years.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in CDH1 or NF1 — beginning at age 30.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in ATM, CHEK2, or NBN — beginning at age 40.; CATEGORY 2 (high genetic risk screening): Carry a genetic mutation in BARD1, RAD51C, or RAD51D — beginning at age 40.; CATEGORY 2 (high genetic risk screening): Confirmed presence of BRCA1 or BRCA2 mutation — beginning at age 25 years.; CATEGORY 2 (high genetic risk screening): First-degree blood relative with BRCA1 or BRCA2 mutation and are untested.; CATEGORY 2 (high genetic risk screening): Have a lifetime risk of breast cancer of 20 to 25% or more using standard risk assessment models (BRCAPRO, Claus model, Gail model, or Tyrer-Cuzick).; CATEGORY 3: To detect intra-capsular (silent) rupture of silicone gel-filled breast implants. NOTE: screening for silent intra-capsular rupture more frequently than every 2 years is NOT considered medically necessary.; CATEGORY 4: Phyllodes tumor (cystosarcoma phyllodes) — indicated preoperatively to establish extent of disease, where diagnosis has been established by biopsy.; CATEGORY 5: Newly diagnosed Paget's disease.; CATEGORY 6: To follow-up a probable benign lesion on MRI (BI-RADS 3 lesions) that was originally detected by MRI — follow-up MRI of BI-RADS 3 lesions is considered medically necessary every 6 months for up to 2 years; if repeat imaging is BI-RADS 1 or 2, then imaging reverts to routine per individual's risk profile. (MRI is NOT considered medically necessary for the initial evaluation of BI-RADS 3 lesions.). Applies to 8 codes: 77046, 77047, 77048, 77049, 19085, 19086, 19287, 19288. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Lead-in: The following breast MRI indications are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established (not an all-inclusive list).; Experimental/investigational: Dermatomyositis as an indication for use of MRI for breast cancer screening.; Experimental/investigational: Follow-up/surveillance of Paget's disease.; Experimental/investigational: Quantitative measurements of breast density.; Experimental/investigational: Screening of persons with APC or GALNT12 mutations.; Experimental/investigational: Surveillance of asymptomatic individuals with breast cancer or carcinoma in situ who have completed primary therapy and who are not at high genetic risk of breast cancer.; Experimental/investigational: To confirm implant rupture in symptomatic individuals whose ultrasonography shows rupture, especially with implants more than 10 years old (ultrasound is sufficient to proceed with removal).; Experimental/investigational: To diagnose fat necrosis post-breast reduction surgery.; Experimental/investigational: To differentiate benign from malignant breast disease, especially clustered micro-calcifications.; Experimental/investigational: To differentiate cysts from solid lesions (ultrasound indicated).; Experimental/investigational: To evaluate breasts before biopsy in an effort to reduce the number of surgical biopsies for benign lesions.; Experimental/investigational: To evaluate suspicious (BI-RADS 4 or 5) lesions found on mammogram and/or ultrasound (a lesion categorized as BI-RADS 4 or 5 should be biopsied).; Experimental/investigational: To evaluate persons with lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), or atypical ductal hyperplasia (ADH).; Experimental/investigational: To evaluate retro-pectoral fat grafting in breast reduction.; Experimental/investigational: To provide an early prediction of response to adjuvant breast cancer chemotherapy in guiding choice of chemotherapy regimen.; Experimental/investigational: To screen for breast cancer in members with average risk of breast cancer.; Experimental/investigational: To screen BRCA-positive men.; Experimental/investigational: To screen individuals with MUTYH mutation.; Experimental/investigational: Women with dense breasts and/or fibrocystic breast disease who are asymptomatic and have no additional risk factors.; Experimental/investigational: Post-surgical intra-operative breast MRI for quantifying tumor deformation and detecting residual breast cancer.; Experimental/investigational: Quantitative breast MRI for predicting the risk of breast cancer recurrence.; Not medically necessary (frequency limit): Screening for silent intra-capsular rupture of silicone gel-filled breast implants more frequently than every 2 years is not considered medically necessary.; Not medically necessary: MRI is not considered medically necessary for the initial evaluation of BI-RADS 3 lesions.; Not separately reimbursed: Aetna considers computer-aided detection of malignancy integral to MRI of the breast and not separately reimbursed. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Breast MRI?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Breast MRI?
Policy exclusions and limitations: Lead-in: The following breast MRI indications are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established (not an all-inclusive list).; Experimental/investigational: Dermatomyositis as an indication for use of MRI for breast cancer screening.; Experimental/investigational: Follow-up/surveillance of Paget's disease.; Experimental/investigational: Quantitative measurements of breast density.; Experimental/investigational: Screening of persons with APC or GALNT12 mutations.; Experimental/investigational: Surveillance of asymptomatic individuals with breast cancer or carcinoma in situ who have completed primary therapy and who are not at high genetic risk of breast cancer.; Experimental/investigational: To confirm implant rupture in symptomatic individuals whose ultrasonography shows rupture, especially with implants more than 10 years old (ultrasound is sufficient to proceed with removal).; Experimental/investigational: To diagnose fat necrosis post-breast reduction surgery.; Experimental/investigational: To differentiate benign from malignant breast disease, especially clustered micro-calcifications.; Experimental/investigational: To differentiate cysts from solid lesions (ultrasound indicated).; Experimental/investigational: To evaluate breasts before biopsy in an effort to reduce the number of surgical biopsies for benign lesions.; Experimental/investigational: To evaluate suspicious (BI-RADS 4 or 5) lesions found on mammogram and/or ultrasound (a lesion categorized as BI-RADS 4 or 5 should be biopsied).; Experimental/investigational: To evaluate persons with lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), or atypical ductal hyperplasia (ADH).; Experimental/investigational: To evaluate retro-pectoral fat grafting in breast reduction.; Experimental/investigational: To provide an early prediction of response to adjuvant breast cancer chemotherapy in guiding choice of chemotherapy regimen.; Experimental/investigational: To screen for breast cancer in members with average risk of breast cancer.; Experimental/investigational: To screen BRCA-positive men.; Experimental/investigational: To screen individuals with MUTYH mutation.; Experimental/investigational: Women with dense breasts and/or fibrocystic breast disease who are asymptomatic and have no additional risk factors.; Experimental/investigational: Post-surgical intra-operative breast MRI for quantifying tumor deformation and detecting residual breast cancer.; Experimental/investigational: Quantitative breast MRI for predicting the risk of breast cancer recurrence.; Not medically necessary (frequency limit): Screening for silent intra-capsular rupture of silicone gel-filled breast implants more frequently than every 2 years is not considered medically necessary.; Not medically necessary: MRI is not considered medically necessary for the initial evaluation of BI-RADS 3 lesions.; Not separately reimbursed: Aetna considers computer-aided detection of malignancy integral to MRI of the breast and not separately reimbursed. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0105 — Breast MRI

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0105 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.