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Breast Imaging for Screening and Diagnosing Cancer
Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Oct 3, 2026
Summary
UnitedHealthcare Community Plan (Medicaid) revised its breast imaging policy effective December 1, 2026, narrowing coverage criteria for advanced imaging (MRI, molecular breast imaging, CT) by clarifying genetic risk factors, dense breast tissue categories, and family history requirements. The policy tightened language around unproven modalities and removed certain imaging technologies from coverage consideration, requiring billing teams to validate medical necessity against specific genetic mutations, risk percentages, and age thresholds before claims submission.
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What to do
by Nov 30, 2026 · 6 steps
01Billing and clinical teams must update prior authorization workflows and claim denial protocols for Medicaid plans to align with revised coverage criteria.
02Update clinical decision support tools in billing system to flag claims for breast MRI, molecular breast imaging (BSGI, scintimammography), CT breast, and magnetic resonance elastography as requiring prior authorization verification against the specific criteria listed (genetic mutations, dense breast categories C/D, family history, lifetime risk ≥20%, prior thoracic radiation, personal cancer history).
03Remove from coverage and prepare denial templates for: Computer-Aided Tactile Breast Imaging, CT of breast, Magnetic Resonance Elastography of the Breast, MRI for patients not meeting high-risk criteria, and Molecular Breast Imaging for routine screening.
04Train billing staff to require providers to document: specific genetic mutation status (BRCA1/2, TP53, PTEN, ATM, CHEK2, PALB2, RAD51C/D, STK11, CDH1, NF1, BARD1), breast density category (C or D only), family history details with degree of relation and age at diagnosis, or risk calculation model results (Gail, Claus, Tyrer-Cuzick, BRCAPRO) showing ≥20% lifetime risk.
05Update encounter forms and EMR templates to capture these data elements before claim submission.
06Implement system rules to reject or route for manual review any Medicaid breast imaging claims lacking documented medical necessity per the revised criteria.
If missed: Failure to implement these changes will result in claim denials and rework on Medicaid submissions starting December 1, 2026.
Original notice
Breast Imaging for Screening and Diagnosing Cancer
uhcprovider.com · Always check the source before changing claims.
Related changes
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