Magnetic Resonance Imaging (MRI) of the Breast

POLICY NUMBER

L.6.01.414

DESCRIPTION

Magnetic resonance imaging (MRI) is a multiplanar imaging method based on an interaction between radiofrequency (RF) electromagnetic fields and certain nuclei in the body (usually hydrogen nuclei) after the body has been placed in a strong magnetic field. MRI differentiates between normal and abnormal tissues, providing a sensitive examination to detect disease. This sensitivity is based on the high degree of inherent contrast due to variations in the magnetic relaxation properties of different tissues, both normal and diseased, and the dependence of the MRI signal on these tissue properties.

MRI is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The magnet creates a strong magnetic field that aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body, and they produce a faint signal that is detected by the receiver portion of the MRI scanner. The receiver information is processed by a computer, and an image is produced. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. For some procedures, contrast agents, such as gadolinium, are used to increase the accuracy of the images.

High-quality breast imaging evaluation is necessary to detect early or subtle breast lesions. Several imaging modalities are commonly available and in clinical use for image-guided breast interventions, including mammographic stereotactic guidance, ultrasound, and magnetic resonance imaging (MRI). The choice of guidance technique will depend on lesion visualization, lesion access, availability of the imaging modality, efficiency, safety, and the experience of the physician performing the biopsy.

Properly performed and interpreted, MRI not only contributes to diagnosis but also can guide treatment planning, help predict outcome, and increase diagnostic confidence. However, MRI should be performed only for a valid medical reason, and only after careful consideration of alternative imaging modalities. The strengths of MRI and other modalities should be weighed as to their suitability in particular patients and in particular clinical conditions.

 Related medical policies are -

• Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast

• Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome (BRCA1/BRCA2)

• Magnetic Resonance Imaging (MRI) of the Abdomen and Pelvis

• Magnetic Resonance Imaging (MRI) of the Lower Extremity

• Magnetic Resonance Imaging (MRI) of the Orbit, Face, Temporomandibular Joint (TMJ) and Neck

• Magnetic Resonance Imaging (MRI) of the Upper Extremity

• Magnetic Resonance Imaging (MRI) of the Spine

• Magnetic Resonance Imaging (MRI) of the Brain and Head

• Magnetic Resonance Imaging (MRI) of the Chest and Cardiac

POLICY

Provider Accreditation for MRI – Network Providers

All Network Providers billing the technical component of the MRI must be accredited in MRI by the Intersocietal Accreditation Commission (IAC) or a MRI module by the American College of Radiology (ACR) or RadSite. The professional component of the MRI will be reimbursed based upon the accreditation of the facility as the ACR, IAC or RadSite facility accreditations require that interpreting professional physicians also be accredited.

A. Magnetic resonance imaging (MRI) of the breast using scanners equipped with breast coils is considered medically necessary for screening for breast cancer in patients that meet the following criteria:

1. With a known BRCA1 or BRCA2 mutation

2. At high risk of BRCA1 or BRCA2 mutation due to a known presence of the mutation in relatives

3. Who have Li-Fraumeni syndrome or Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or who have a first-degree relative with one of these syndromes

4. At high risk (lifetime risk about 20% to 25% or greater) of developing breast cancer as identified by models that are largely defined by family history (See Policy Guidelines)

5. Who received radiation therapy to the chest between 10 and 30 years of age.

B. Magnetic resonance imaging (MRI) of the breast using scanners equipped with breast coils is considered medically necessary for the following indications:

1. For preoperative tumor mapping of the involved (ipsilateral) breast to evaluate the presence of multicentric disease in individuals with clinically localized breast cancer who are candidates for breast-conservation therapy 

2. For detection of a suspected occult breast primary tumor in individuals with axillary nodal adenocarcinoma (e.g., negative mammography and physical exam)

3. For presurgical planning in patients with locally advanced breast cancer before and after completion of neoadjuvant chemotherapy to permit tumor localization and characterization

4. To determine the presence of pectoralis major muscle/chest wall invasion in individuals with posteriorly located tumor

5. To detect local tumor recurrence in individuals with breast cancer history who has undergone mastectomy AND breast reconstruction with an implant

6. To detect local tumor recurrence in individuals with breast cancer history who have radiographically dense breasts or old scar tissue from previous breast surgery that compromises the ability of combined mammography AND ultrasound

7. To detect and stage invasive lobular carcinoma (ILC) for tailored therapy (e.g., breast conservation therapy)

8. A mass, distortion, or abnormality in breast of an individual with a history of breast cancer and the individual has had a prior mammogram and ultrasound

9. Axillary mass with negative mammogram in a patient without history of breast cancer

10. Post surgical or post treatment evaluation for possible residual tumor

11. To detect or confirm silicone breast implant leakage or rupture implanted for non-cosmetic purposes confirmed or not confirmed by the following diagnostic procedures: a.     Mammography to determine if a problem exists related to ruptured breast implant(s) (e.g., evaluate and isolate breast tissue from breast implant); OR b.     Ultrasound of the breast to determine if ruptures or leaks are present in breast implant(s)

12. For evaluation of the contralateral breast in individuals with a new diagnosis of breast cancer who have normal clinical and mammographic findings in the contralateral breast

13. For evaluation of a documented abnormality of the breast prior to obtaining an MRI-guided biopsy when there are documentation that other method (e.g., breast palpation, breast ultrasound) are not able to localize the lesion for biopsy

14. For investigation of bloody nipple discharge

15. For evaluation of inflammatory breast cancer with unknown or unlocalized intrabreast primary.

C. Magnetic resonance imaging (MRI) of the breast is considered not medically necessary for all other indications, including but not limited to the following:

1. When used in lieu of a tissue biopsy to diagnose breast cancer

2. As a screening technique in the general population

3. Saline breast implant leakage/rupture not confirmed by mammography or ultrasound of the breast  

4. As a screening technique for the detection of breast cancer when the sensitivity of mammography is limited (i.e., dense breasts, implants, scarring after treatment for breast cancer)

5. For the diagnosis of low-suspicion findings on conventional testing not indicated for immediate biopsy and referral for short-interval follow-up

6. For the diagnosis of a suspicious breast lesion i.e., in order to avoid biopsy

7. For determining the response during neoadjuvant chemotherapy in patients with locally advanced breast cancer

8. When performed without the use of a breast coil, regardless of the clinical indication.

POLICY EXCEPTIONS

State Health Plan (SHP) Members:For dates of service on or prior to 12/31/2015, this policy applies to MRI of the breast when performed in the emergency room. This policy does not apply to MRI of the breast performed in non-emergency room settings.  MRI of the breast performed in non-emergency room settings require pre-certification by the Plan’s Utilization Review Vendor.

Effective 01/01/2016, this policy applies to MRI of the breast performed in all settings for State Health Plan Members.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

A number of models can assist practitioners in estimating breast cancer risk using family history, including the Claus, modified Gail, Tyrer, and BRCAPRO models.

Reimbursement for MRI imaging of the same anatomical area is generally limited to one (1) MRI imaging within a 6-month period. MRI imaging in excess of one (1) within a 6-month period will be subject to medical necessity review. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Additional MRI imaging of the same anatomical area may be appropriate for the following, including, but not limited to: diagnosis, staging or follow-up of cancer, follow-up assessment during or after therapy for known metastases, follow-up of member who have had an operative, interventional or therapeutic procedure (e.g., surgery, embolization), reevaluation due to change in clinical status (e.g., deterioration), new or worsening clinical findings, (e.g., neurologic signs, symptoms), medical intervention which warrants reassessment, reevaluation for treatment planning, follow-up during and after completion of therapy or treatment to assess effectiveness, and evaluation after intervention or surgery.

Re-imaging or additional imaging due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

05/19/2014: New policy added. Approved by Radiology Physician Advisory Committee and Medical Policy Advisory Committee. Effective 09/15/2014.

06/30/2014: Policy Exceptions section updated regarding SHP members to state that this policy applies to MRI of the breast when performed in the emergency room. This policy does not apply to MRI of the breast performed in non-emergency room settings. MRI of the breast performed in non-emergency room settings require pre-certification by the Plan’s Utilization Review Vendor.

09/05/2014: Code Reference section updated to change CPT code "77053" to "77059" and add diagnosis codes V67.00, V67.09, V67.1, V67.51, V67.59, V67.6, V67.9, and V72.84.

08/26/2015: Medical policy revised to add ICD-10 codes.

12/31/2015: Policy Exceptions section updated regarding SHP members to state that effective 01/01/2016, this policy applies to MRI of the breast performed in all settings for State Health Plan Members.

06/08/2016: Policy number L.6.01.414 added. Policy Guidelines updated to add medically necessary definition.

09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes N61.0 and N61.1.

09/29/2017: Code Reference section updated to add new ICD-10 diagnosis codes N63.0, N63.10, N63.11, N63.12, N63.13, N63.14, N63.20, N63.21, N63.22, N63.23, N63.24, N63.31, N63.32, N63.41, and N63.42, effective 10/01/2017. Removed deleted ICD-10 diagnosis codes N61 and T85.81XA - T85.89XS.

12/18/2018: Code Reference section updated to add new CPT codes 77046, 77047, 77048, and 77049, effective 01/01/2019.

09/30/2020: Code Reference section updated to add new ICD-10 diagnosis codes N61.20, N61.21, N61.22, and N61.23, effective 10/01/2020. Removed deleted CPT codes 77058 and 77059.

10/01/2021: Code Reference section updated to add new ICD-10 diagnosis code C84.7A, effective 10/01/2021.

09/30/2022: Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to add new ICD-10 diagnosis code Q85.89, effective 10/01/2022.

11/21/2022: Policy reviewed; no changes.

12/04/2023: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis code Q85.8.

08/27/2024: Code Reference section updated to remove deleted ICD-10 diagnosis codes T85.82XA - T85.82XS, T85.83XA - T85.83XS, T85.84XA - T85.84XS, T85.85XA - T85.85XS, T85.86XA - T85.86XS, and T85.89XA - T85.89XS.

12/13/2024: Policy reviewed; no changes.

10/01/2025: Code Reference section updated to add new ICD-10 diagnosis codes C50.A0, C50.A1, and C50.A2.

11/01/2025: Added RadSite as an imaging accreditation body.

SOURCE(S)

1. American College of Radiology. ACR Practice Guideline for Performing and Interpreting Magnetic Resonance Imaging (MRI), 2011.

2. American College of Radiology. American College of Radiology Practice Guideline for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the Breast, 2008.

3. Arkansas Blue Cross Blue Shield Magnetic Resonance Imaging (MRI), Breast

4. Blue Cross Blue Shield Association Policy # 6.01.29

5. http://www.medicinenet.com/mri_scan/article.htm

6. Magnetic Resonance Imaging (MRI) of the Breast medical policy, Blue Cross and Blue Shield of Florida

7. Medical Policy Advisory Committee

8. Radiology Physician Advisory Committee

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.