Breast Magnetic Resonance Imaging
Coverage of a breast Magnetic Resonance Imaging, also known as an MRI, depends on whether the service is a preventive screening or a diagnostic procedure due to symptoms or a confirmed diagnosis.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.
Screening Breast MRI
Screening breast MRIs are not a covered benefit for women considered to be at low or average risk of developing breast cancer.
Screening breast MRIs are covered annually in addition to the annual screening mammogram, beginning at age 30 for beneficiaries considered to be at high risk of developing breast cancer. High-risk indicators are:
- A lifetime risk of breast cancer of 20 percent or greater using standard risk assessment models such as: Gail model, Claus model or Tyrer-Cuzick.
- Known BRCA1 or BRCA2 gene mutation.
- A parent, child or sibling with a BRCA1 or BRCA2 gene mutation, and the beneficiary has not had genetic testing for this mutation.
- Radiation therapy to the chest between 10–30 years of age.
- History of LiFraumeni, Cowden or Bannayan-Riley-Ruvalcaba syndrome, or a parent, child or sibling with a history of one of these syndromes.
Diagnostic Breast MRI
Diagnostic breast MRIs are not a covered benefit for the following:
- evaluation before biopsy
- differentiation between benign and malignant breast disease
- differentiation between cysts and solid lesions
Diagnostic breast MRIs are covered for the following:
- detection of breast implant rupture (the implantation of the breast implants must have been covered by TRICARE)
- detection of occult breast cancer in the setting of axillary nodal adenocarcinoma with negative physical exam and negative mammography
- presurgical planning for locally advanced breast cancer before and after completion of neoadjuvant chemotherapy to permit tumor localization and characterization
- presurgical planning to evaluate the presence of multicentric disease in patients with locally advanced cancer who are candidates for breast conservation treatment
- evaluation of suspected cancer recurrence
- determination of the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumor
- for guidance of interventional procedures such as vacuum assisted biopsy and preoperative wire localization for lesions that are occult on mammography or sonography and are demonstrable only with MRI