UHC Updates their Medical Policy on Breast Imaging for Screening & Diagnosing Cancer

September 22, 2021

United Healthcare has updated their Medical Policy on Breast Imaging for Screening and Diagnosing Cancer, which goes into effect October 1, 2021.  According to the newly updated policy, the following procedures will not be covered, as UHC considers them unproven and not medically necessary due to insufficient evidence of efficacy: 

•    Automated breast ultrasound system
•    Breast magnetic resonance imaging (MRI) for individuals with dense breast tissue not accompanied by defined risk factors as described below
     o    Prior thoracic radiation therapy between the ages 10 and 30 
     o    Lifetime risk estimated at greater than or equal to 20% as defined by models that are largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick or          BRCAPRO) 
     o    Personal history of breast cancer (not treated with bilateral mastectomy)
     o    Personal history with any of the following: 
              Li-Fraumeni Syndrome (TP53 mutation) 
              Confirmed BRCA 1 or BRCA 2 gene mutations 
              Peutz-Jehgers Syndrome (STK11, LKB1 gene variations) 
              PTEN gene mutation 
     o    Family history with any of the following: 
              At least one first-degree relative who has a BRCA1 or BRCA2 mutation 
              First-degree relative who carries a genetic mutation in the TP53 or PTEN genes (Li-Fraumeni syndrome and Cowden and Bannayan-Riley-Ruvalcaba syndromes, or Peutz-Jehgers Syndrome) 
              At least two first-degree relatives with breast or ovarian cancer 
              One first-degree relative with bilateral breast cancer, or both breast and ovarian cancer 
              First or second-degree male relative (father, brother, uncle, grandfather) diagnosed with breast cancer 
•    Computer-aided detection (CAD) for ultrasound and with MRI of the breast
•    Computer-aided tactile breast imaging 
•    Electrical impedance scanning (EIS) 
•    Magnetic resonance elastography (MRE) 
•    Molecular breast imaging (e.g., Scintimammography, positron emission mammography)

Please click here for a full listing of applicable CPT codes, procedure descriptions and clinical rational.  Please note, this policy does not address preventive benefits for breast cancer screening. That information can be found here.