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UnitedHealthcareMedicaid · Coverage · Medical Policy · NJ · Radiology, Oncology, General Surgery +1 moreMedium impact

Breast Imaging for Screening and Diagnosing Cancer (for New Jersey Only)

Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Oct 3, 2026

Summary

UnitedHealthcare Community Plan of New Jersey (Medicaid) revised its breast imaging policy effective December 1, 2026, clarifying coverage criteria for breast MRI in high-risk individuals and refining the list of unproven/non-covered modalities. Key changes include refined definitions of Molecular Breast Imaging and removal of Breast Specific Gamma Imaging as a separate definition. Breast MRI is now clearly covered for specific high-risk populations including those with dense breasts, genetic mutations, personal/family history of breast cancer, and prior chest radiation—but remains non-covered for individuals who do not meet these criteria.

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What to do

by Nov 30, 2026 · 6 steps
01Billing team must update internal policies and prior authorization workflows to reflect revised breast imaging coverage criteria for NJ Medicaid patients.
02Update prior auth submission templates to include required high-risk criteria documentation (dense breast category, genetic mutation status, personal/family history, or prior radiation therapy with dates).
03Train billing and clinical staff on new screening age thresholds for specific genetic mutations (e.g., TP53 starting age 20, BRCA1/2 starting age 25, ATM/CHEK2/NF1/PALB2/PTEN/STK11 starting age 30).
04Implement system rules to deny or request additional documentation for breast MRI claims lacking high-risk criteria.
05Update superbill/encounter forms to prompt providers to document which high-risk category applies.
06Create internal reference guide distinguishing covered indications (breast MRI for high-risk individuals) from non-covered services (MRI for routine screening without risk factors, Molecular Breast Imaging for routine screening, Positron Emission Mammography, CT breast, Magnetic Resonance Elastography).
If missed: Failure to implement these changes will result in improper claim submissions and potential denials for non-compliant claims.

Original notice

Breast Imaging for Screening and Diagnosing Cancer (for New Jersey Only)
uhcprovider.com · Always check the source before changing claims.
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Related changes

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Breast Imaging for Screening and Diagnosing CancerHighEffective Dec 1, 2026 · Medical PolicyBrowse every UnitedHealthcare change in the policy list

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