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Breast Imaging for Screening and Diagnosing Cancer (for Pennsylvania Only)
Effective date
Dec 1, 2026
Identified
Nov 7, 2026
Summary
UnitedHealthcare Community Plan of Pennsylvania revised its Medicaid medical policy for breast imaging for screening and diagnosing cancer, effective 2026-12-01. Magnetic resonance elastography and molecular breast imaging are now listed as unproven and not medically necessary, with the molecular imaging entry narrowed to routine screening in normal or high-risk individuals and positron emission mammography. The coverage rationale also adds a specific MRI-of-the-breast entry for elastography, and the criteria for proven high-risk breast MRI are unchanged in the text provided.
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What to do
Action · 3 steps
01By 2026-12-01: Billing team should review scheduled and planned breast imaging orders for Pennsylvania Medicaid members involving magnetic resonance elastography of the breast, molecular breast imaging (breast-specific gamma imaging, scintimammography) for routine screening, or positron emission mammography, and confirm documentation supports a covered indication before claims are submitted.
02Providers and front desk staff should be told that these services are now listed as unproven and not medically necessary for routine screening under this plan, and that breast MRI for individuals not meeting the high-risk criteria is also listed as not medically necessary.
03Where a service is not covered, the practice should follow its own patient financial policy for member liability, and claims without supporting documentation will be denied under this policy's coverage criteria.
Original notice
Breast Imaging for Screening and Diagnosing Cancer (for Pennsylvania Only)
uhcprovider.com · Always check the source before changing claims.