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Breast Imaging for Screening and Diagnosing Cancer (for New Mexico Only)
Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Oct 3, 2026
Summary
UnitedHealthcare Community Plan of New Mexico (Medicaid) revised its breast imaging policy effective December 1, 2026, narrowing coverage for molecular breast imaging by explicitly excluding routine screening use and clarifying that Positron Emission Mammography is not covered. The policy also refined terminology for MRI elastography and updated clinical evidence. Billing teams must ensure claims for excluded modalities are not submitted for routine screening cases, even in high-risk patients.
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What to do
by Nov 30, 2026 · 4 steps
01Billing team must update claim denial/acceptance rules in billing software to reflect that Molecular Breast Imaging (breast specific gamma imaging, scintimammography) for routine screening—even in high-risk individuals—and Positron Emission Mammography are no longer covered under UnitedHealthcare Community Plan of New Mexico Medicaid.
02Providers must document medical necessity for any breast MRI claims to verify the patient meets high-risk criteria (dense breasts, genetic mutations, prior radiation, strong family history, or personal history of breast cancer).
03Add a pre-billing checklist for New Mexico Medicaid patients requesting breast imaging to confirm eligibility and permitted modalities.
04Train front desk and prior authorization staff to flag breast imaging requests and route them for medical necessity review before submission.
If missed: Failure to comply will result in claim denials and potential member balance issues.
Original notice
Breast Imaging for Screening and Diagnosing Cancer (for New Mexico Only)
uhcprovider.com · Always check the source before changing claims.