CommercialCoverageHigh impact
Magnetic Resonance Imaging (MRI) of the Breast (CPB 0105, reviewed 2026-08-06)
Aetna·Radiology, Oncology, General Surgery +1 more·Radiology
Effective date
Aug 6, 2026
We identified it
Aug 19, 2026
Summary
This is a comprehensive Aetna clinical policy bulletin for breast MRI (CPT 77046-77049) that outlines extensive covered indications, experimental/non-covered uses, and billing code guidance. The policy was reviewed on 2026-08-06 and establishes specific medical necessity criteria for breast MRI with or without contrast, including oncologic staging, implant evaluation, high-genetic-risk screening, and post-treatment surveillance. Billing teams must ensure claims align with the defined covered indications and avoid submitting claims for experimental/investigational indications listed in the policy.
Action Required
By 2026-08-06: Billing team must implement the following controls in the billing system: (1) For CPT codes 77046, 77047, 77048, 77049 (breast MRI), configure system to require documentation of medical necessity matching one of the 20+ covered indications listed in the policy before claim submission. (2) Create a denial protocol for claims submitted for indications listed under 'Experimental, Investigational, or Unproven' section (e.g., screening average-risk members, evaluation of BI-RADS 4/5 lesions, LCIS/DCIS/ADH evaluation, dense breast screening without additional risk factors). (3) For CPT 0697T and 0698T (quantitative MRI), configure system to reject claims automatically as these codes are not covered per this policy. (4) Update pre-authorization templates to require providers document which specific covered indication applies (oncologic staging, implant rupture, high-genetic-risk screening with specific mutation type, etc.). (5) Train billing and pre-auth staff on the 25+ covered indications versus the 15+ non-covered experimental uses to prevent inappropriate claim denials and appeals. Providers must document in clinical notes which covered indication justifies the MRI order. Failure to align claims with covered indications will result in denials from Aetna Commercial plans.