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Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only)
Act
by Nov 1, 2026
Effective date
Dec 1, 2026
Identified
Oct 3, 2026
Summary
UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its breast imaging policy effective December 1, 2026, clarifying coverage criteria for MRI breast screening in high-risk individuals while designating several advanced imaging modalities (including Molecular Breast Imaging for routine screening and Positron Emission Mammography) as unproven and not medically necessary. The policy removed the standalone BSGI definition and refined language around MRI indications, genetic risk criteria, and age thresholds for screening initiation.
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What to do
by Nov 1, 2026 · 6 steps
01Billing and clinical teams must update internal policies and prior authorization workflows for Kentucky Medicaid to align with the new breast imaging coverage criteria.
02Providers must document patient risk stratification using the listed criteria (dense breasts, prior thoracic radiation, lifetime risk models, genetic mutations, family history) before ordering breast MRI for screening.
03Billing team must deny or retroactively process claims for Molecular Breast Imaging (BSGI, scintimammography) for routine screening, Positron Emission Mammography, and Magnetic Resonance Elastography of the Breast as non-covered services unless submitted with documented medical necessity beyond routine screening.
04Update prior authorization request forms in the billing system to reflect only covered high-risk indications and remove references to the old BSGI definition.
05Flag orders for Computer-Aided Tactile Breast Imaging and CT breast imaging for denial as insufficient evidence.
06Train front-desk and clinical staff to communicate to patients that routine preventive mammography coverage remains unchanged and is not addressed by this policy.
If missed: Failure to apply these criteria will result in claim denials and potential patient balance billing disputes.
Original notice
Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only)
uhcprovider.com · Always check the source before changing claims.