MRI of the breast is considered eligible for patients at high risk for breast cancer when prior mammography and/or ultrasound studies are inconclusive or equivocal and there is still the suspicion of breast cancer, or when a diagnosis of breast cancer is confirmed and requires further evaluation for lesion characterization prior to treatment. 

High risk factors

• Presence of known BRCA1 or BRCA2 genetic mutation (V84.01)
• Possible BRCA1 or BRCA2 genetic mutation in a high risk patient consistent with a known BRCA1 or BRCA2 mutation in a family member with breast cancer (V16.3)
• Breast cancer history in multiple first-degree relatives, often occurring at a young age and with bilaterality, consistent with a high probability of harboring BRCA mutations or other hereditary breast cancer (V16.3)

Additional Covered Indications

• Evaluation for the presence of breast cancer or for additional lesions following a diagnosis and/or treatment of breast cancer in male or female patients. Examples include but are not limited to: very dense breast tissue, mammographic microcalcification, dysplasia or severe fibrocystic changes, infiltrating lobular or ductal carcinoma, presence of pectoralis major muscle/chest wall invasion in patients with a posteriorly located tumor, or carcinoma invasion deep to fascia (174.0-174.9, 175.0-175.9, 198.81, 233.0, 238.3, 239.3, 610.2, 611.72, 611.79, 611.8, 793.80, 793.81, 793.89, 793.9)
• Detection of suspected occult breast primary tumor in patients with axillary nodal adenocarcinoma (785.6)
• For presurgical planning in patients with locally advanced breast cancer before, during and/or after completion of neoadjuvant chemotherapy (for example, to permit tumor localization and characterization, evaluate chemotherapeutic response and/or residual disease prior to surgery)
• Detection of a rupture of silicone or non-silicone breast augmentation or implant(s)(996.54, V43.82)

MRI studies of the breast for all other indications, including its use as a screening procedure, are considered experimental/investigational. Scientific evidence does not demonstrate that MRI of the breast impacts or improves health outcomes. A participating, preferred, or network provider can bill the member for services denied as experimental/investigational.

Payment is made for paramagnetic contrast material (codes A4647, Q9952, Q9953, or Q9954, as appropriate) in addition to the MRI procedure. The diagnostic imaging agent/contrast material used in conjunction with an eligible imaging procedure is eligible when administered by the health care professional in a setting other than a hospital or a skilled facility.

When charges for additional acquisitions, cuts, slices, etc., are billed separately, the charges are combined and paid under the appropriate code for the study performed.

When both MRI and a computed tomography (CT) scan are performed on the same day for the same anatomic area, payment should be made for the CT scan. The MRI may only be paid if supporting documentation is submitted to establish medical necessity for both studies.

Description

Magnetic resonance imaging, also referred to as nuclear magnetic resonance (NMR), is a noninvasive diagnostic imaging modality. The technique uses the interaction of a magnetic field and radiofrequency waves to generate, with computer assistance, an image of an area of the body.

For additional information on MRI see Medical Policy Bulletin X-2.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. MRI of the breast for conditions other than those listed as eligible on this policy is eligible when determined medically necessary based on the patient’s condition.

PRN References

04/1995, MRI of the breast
04/1999, Coverage for breast MRI expanded
06/2005, Blue Shield expands coverage for MRI of the breast

Special Bulletin

07/2000, MRI and CT studies performed on the same day

Magnetic Resonance Imaging of the Breast Prior to Biopsy, Journal of the American Medical Association, Vol. 292, No. 22, December 2004

Surveillance of BRCA1 and BRCA2 Mutation Carriers with Magnetic Resonance Imaging, Ultrasound, Mammography, and Clinical Breast Examination, Journal of the American Medical Society, Vol. 22, No. 11, September 2004

Efficacy of MRI and Mammography for Breast-Cancer Screening in Women with a Familial or Genetic Predisposition, The New England Journal of Medicine, Vol. 351, No. 5, July 2004

Breast Cancer Screening with MRI – What Are the Data for Patients at High Risk? – An Editorial, The New England Journal of Medicine, Vol. 351., No. 5, September 2004

National Blue Cross Blue Shield Medical Policy 6.01.29

Magnetic Resonance Imaging of the Breast for Preoperative Evaluation in Patients with Localized Breast Cancer, National Blue Cross Blue Shield TEC Assessment, September 2004

Breast MRI for Management of Patients with Locally Advanced Breast Cancer Who Are Being Referred for Neoadjuvant Chemotherapy, National Blue Cross Blue Shield TEC Assessment, September 2004

American Society of Breast Disease Policy Statement: The Use of Magnetic Resonance Imaging of the Breast (MRIB) for Screening of Women at High Risk of Breast Cancer, June 2004

Website of the National Cancer Institute