Medicare AdvantageCoverageHigh impact
Breast Imaging - Medicare Advantage (Revised)
Humana·Radiology, Oncology, General Surgery +1 more·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Sep 2, 2026
Summary
This is a comprehensive Medicare Advantage breast imaging policy (effective 07/01/2026) that establishes coverage criteria for mammography, digital breast tomosynthesis, breast MRI, and ultrasound. The policy clarifies medical necessity standards across different imaging modalities and specifies screening breast MRI eligibility based on genetic variants, familial risk, lifetime risk calculations (≥20%), male breast cancer history, or prior chest radiation. Billing teams must apply jurisdiction-specific LCDs where applicable or use the referenced criteria for consistent coverage determination.
Action Required
By 06/30/2026: (1) Billing team must update claims processing system to recognize effective date 07/01/2026 for this revised Medicare Advantage breast imaging policy. (2) Configure system to route claims to appropriate jurisdiction-specific LCDs (L33585 for J6/JK/JE/JF/JH/JL/JJ/JM/JN; L33950 for J15 jurisdictions). (3) For screening breast MRI claims (CPT 77046-77049, C8903, C8905, C8906, C8908): implement requirement to verify at least one qualifying criterion before processing—genetic testing results, family history documentation, lifetime risk assessment ≥20% (using BRCAPRO, BOADICEA, Tyrer-Cuzick), first/second-degree male breast cancer relative, or chest radiation history (age 10-30). (4) Update prior authorization templates and decision trees to reflect genetic-specific age recommendations (BRCA1/BRCA2 age 25+; ATM/CDH1/CHEK2/PALB2/STK11 age 30+; BARD1/RAD51C/RAD51D age 40+; TP53 age 20+; NF1 age 30-50; PTEN age 30+). (5) Providers must document medical necessity and risk factors on encounter forms for all breast imaging claims. (6) Denial consequences: Claims without supporting medical necessity documentation or approved criteria will be denied as not medically reasonable and necessary per Medicare Advantage requirements.