MRI Breast - CAM 764HB

Magnetic resonance imaging (MRI) of the breast is a useful tool for the detection and characterization of breast disease, assessment of local extent of disease, evaluation of treatment response, and guidance for biopsy and localization.34 Breast MRI should always be bilateral to allow for assessment of symmetry between the breasts. MRI findings should be correlated with clinical history, physical examination, and the results of mammography and any other prior breast imaging.

MRI and risk evaluation — The age of a family member’s diagnosis is only relevant for patients under the age of 40. Anyone 40 or over should be getting annual mammograms and breast MRIs if their lifetime risk is 20% or greater.

Nipple discharge — Nipple discharge is a common complaint with at least 80% of women having at least 1 episode. Discharge that is considered pathologic is unilateral, spontaneous, from one duct orifice and serous or bloody. Physiologic discharge will be bilateral, from multiple ducts, and white, green, or yellow in color. “In general, MRI may be considered in cases in which mammography and US have failed to identify an underlying cause of pathologic nipple discharge. The sensitivities of breast MRI for detecting the cause of the pathologic nipple discharge are 86% to 100% for invasive cancer and 40% to 100% for noninvasive disease”.35 Ductography (galactography) has the ability to demonstrate small lesions in the specific duct that is secreting the pathologic nipple discharge. However, it is invasive and may cause discomfort and pain. It can be time-consuming and technically challenging and the rate of inadequate or incomplete ductography is as high as 15%. The discharge must be present on the day of the study so that a cannula can be placed in the appropriate duct. Failure to cannulate the discharging duct may occur and cannulation of the wrong duct may cause a false-negative ductogram.35


It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.



Dense breast tissue on mammography

  • Inconclusive screening mammogram when category 0 has been specifically assigned due to breast characteristics limiting the sensitivity of mammography (e.g., extremely or heterogeneously dense breast, implants obscure breast tissue)

High-risk screening breast MRI

  • A Breast Cancer Risk Assessment (including the Breast Cancer Consortium Risk Model (BCSC) which incorporates breast density, the International Breast Cancer Intervention Study (IBIS)/Tyrer-Cuzick model, the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm model (BOADICEA), the modified Gail (also known as the Breast Cancer Risk assessment tool (BCRAT)) or other validated risk assessment models) that identifies the patient as having a lifetime risk of 20% or greater of developing breast cancer1
    • Approve annually beginning 10 years prior to youngest family member’s age at diagnosis or at age 40, whichever comes first, but not before age 252,3,4,5,6
  • Patients with lifetime risk of 20% or greater of developing breast cancer based on history of lobular neoplasia (LCIS/ALH (Lobular Carcinoma in Situ /Atypical Lobular Hyperplasia)) or ADH (atypical ductal hyperplasia)
    • Approve annually beginning at age of diagnosis of LCIS/ALH or ADH but not prior to age 252
  • Patients with intermediate lifetime risk (15% – 20%) of developing breast cancer based on a history lobular neoplasia (LCIS/ALH (Lobular Carcinoma in Situ /Atypical Lobular Hyperplasia)) or ADH (atypical ductal hyperplasia)) AND have dense breast tissue on mammography
    • Approve annually beginning at age of diagnosis of LCIS/ALH or ADH but not prior to age 252,7,8
  • Patients with history of extensive chest irradiation (usually as treatment for Hodgkin’s or other lymphoma between ages 10 and 30)
    • Begin eight years after radiation, but not prior to age 252
  • Patients with known BRCA 1/2 mutation
    • Approve annually starting at age 252,3
  • Patients not yet tested for BRCA gene, but with known BRCA mutation in first-degree relative
    • Approve annually starting at age 252,3
  • Personal history of germline mutations known to predispose to a high risk of breast cancer:1
    • Li-Fraumeni syndrome (TP53 mutation)
      • Begin age 20 – 29 or age at earliest diagnosed breast cancer in family, if younger than age 20
  • Cowden syndrome (PTEN) or Bannayan-Riley-Ruvalcaba syndrome (BRRS)
    • Begin age 35 or 10 years before earliest breast cancer diagnosis in family, whichever comes first (NCCN 2022)
  • ATM
    • Begin age 30 – 35 years
  • BARD1
    • Begin age 40
  • CDH1
    • Begin age 30
  • CHEK2
    • Begin age 30 – 35 years
  • NF1
    • Begin age 30, end age 502
  • PALB2
    • Begin age 30
  • Peutz-Jeghers Syndrome (STK11)
    • Begin age 30
  • RAD51C
    • Begin age 40
  • RAD51D
    • Begin age 40

+For screening examination to detect breast cancer in any of the following situations. It is appropriate to perform screening breast MRI at routine intervals in patients at increased risk who are lactating.
Contrast-enhanced MRI is not recommended during pregnancy due to the trans-placental passage of gadolinium and potential concern for the exposure of the fetus to gadolinium.

For evaluation of identified lesion, mass, or abnormality in breast in any of the following situations

  • Evaluation of suspected breast cancer when other imaging examinations, such as ultrasound and mammography, and physical examination are inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g., seen only in single view mammogram without ultrasound correlation)
    • Includes skin changes of suspected inflammatory breast cancer if conventional imaging and skin biopsies are first performed and negative3,9,10
  • For evaluation of suspicious mass, lesion, distortion, or abnormality of the breast in patient with history of breast cancer when other imaging is inconclusive
  • For cases of new nipple inversion when mammographic and sonographic findings are inconclusive, and a biopsy cannot be performed11,12,13
  • Patients diagnosed with biopsy-proven lobular neoplasia, i.e., LCIS/ALH (Lobular Carcinoma in Situ /Atypical Lobular Hyperplasia) or ADH (atypical ductal hyperplasia)2,3,14,15
  • Spontaneous unilateral serous or bloody nipple discharge when conventional imaging is interpreted as BI-RADS 1-3 and there is no palpable mass thought to be related to the discharge2,3,16
  • Paget’s disease of the nipple: to detect underlying ductal carcinoma when conventional imaging
  • is interpreted as BI-RADS 1-3 and there is no palpable mass3
  • For a phyllodes tumor diagnosed by biopsy, breast MRI may help determine extent of disease and resectability in selected cases. However routine use for surgical planning is controversial17,18,19
  • Follow-up of a probably benign (BI-RADS 3) lesion seen only on prior MRI (when prior mammogram and ultrasound did not show the abnormality)20,21,22


  • Yearly surveillance for history of breast cancer and dense breast tissue on mammography4
  • Yearly surveillance for individuals with personal history of breast cancer diagnosed before age 504
  • Yearly surveillance in patients with genetic or other risk factors placing them at high risk for a new cancer or recurrence3,23
  • Yearly surveillance for individuals with a mammographically occult primary breast cancer24

Staging, treatment, and surveillance of patients with a known history of breast cancer

  • Approve for initial staging when conventional imaging is indeterminate in defining the extent of cancer, or presence of multifocal, multicentric, or contralateral cancer, or if there is a discrepancy in estimated tumor size between physical exam and imaging2,3,14
  • For invasive lobular carcinoma that is poorly or inadequately defined by mammography, ultrasound, or physical exam2,14
  • To identify primary cancer in a patient with axillary nodal adenocarcinoma and unidentified primary tumor2
  • Prior to treatment: To serve as a baseline for comparison prior to a patient starting planned neoadjuvant chemotherapy25
  • During or after treatment: To identify candidates for breast conserving therapy or evaluate response to treatment, including preoperative neoadjuvant therapy [within three months]3

Silicone Implants
MRI is not indicated for evaluation of saline implant complications or for asymptomatic silicone implants.4,26

  • Confirmation of suspected silicone gel-filled breast implant ruptures in asymptomatic patients, after an abnormal or indeterminate finding on mammography or breast ultrasound
  • MRI is considered the gold standard for evaluation of symptomatic silicone implant rupture.3,4 Prior imaging is not required in patients with silicone implants and symptoms of possible rupture.
  • For postoperative evaluation of silicone breast implant complications when other imaging is inconclusive


  • For preoperative evaluation for known breast cancer when surgery planned within thirty (30) days to be determined on a case-by-case basis3,14,27,28

Post-operative/procedural evaluation
A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.4

Other Indications
Further evaluation of indeterminate findings on prior imaging (unless follow up is otherwise specified within the guideline):

  • For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification
  • One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred. (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)


  1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic Version 2.2023. National Comprehensive Cancer Network (NCCN). Updated January 10, 2023. Accessed January 19, 2023.
  2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Breast Cancer Screening and Diagnosis Version 1.2022. National Comprehensive Cancer Network (NCCN). Updated June 2, 2022. Accessed November 20, 2022. screening.pdf
  3. Consensus Guideline on Diagnostic and Screening Magnetic Resonance Imaging of the Breast. American Society of Breast Surgeons (ASBrS). Updated June 22, 2017. Accessed December 17, 2021. June 22, 2017
  4. ACR practice parameter for the performance of contrast-enhanced magnetic resonance imaging (MRI) of the breast. American College of Radiology. Updated 2018. Accessed November 20, 2022.
  5. Levitan D. Which Breast Cancer Risk Models Are Most Accurate? Cancer Network. Updated February 27, 2019. Accessed November 20, 2022. risk-models-are-most-accurate
  6. Marino MA, Riedl CC, Bernathova M, et al. Imaging Phenotypes in Women at High Risk for Breast Cancer on Mammography, Ultrasound, and Magnetic Resonance Imaging Using the Fifth Edition of the Breast Imaging Reporting and Data System. Eur J Radiol. Sep 2018;106:150-159. doi:10.1016/j.ejrad.2018.07.026
  7. Feldman L, Babagbemi K. Patient-Friendly Summary of the ACR Appropriateness Criteria: Supplemental Breast Cancer Screening Based on Breast Density. J Am Coll Radiol. May 2022;19(5):e29. doi:10.1016/j.jacr.2022.02.008
  8. Expert Panel on Breast I, Weinstein SP, Slanetz PJ, et al. ACR Appropriateness Criteria(®) Supplemental Breast Cancer Screening Based on Breast Density. J Am Coll Radiol. Nov 2021;18(11S):S456-S473. doi:10.1016/j.jacr.2021.09.002
  9. Giess CS, Chikarmane SA, Sippo DA, Birdwell RL. Clinical Utility of Breast MRI in the Diagnosis of Malignancy After Inconclusive or Equivocal Mammographic Diagnostic Evaluation. AJR Am J Roentgenol. Jun 2017;208(6):1378-1385. doi:10.2214/ajr.16.16751
  10. Yadav P, Chauhan S. Effectivity of combined diffusion-weighted imaging and contrast-enhanced MRI in malignant and benign breast lesions. Pol J Radiol. 2018;83:e82-e93. doi:10.5114/pjr.2018.74363
  11. Killelea B, Snowden M. Nipple inversion. Wolters Kluwer. Updated February 16, 2022. Accessed November 20, 2022.
  12. Del Riego J, Pitarch M, Codina C, et al. Multimodality approach to the nipple-areolar complex: a pictorial review and diagnostic algorithm. Insights Imaging. Aug 5 2020;11(1):89. doi:10.1186/s13244- 020-00896-1
  13. Geffroy D, Doutriaux-Dumoulins I. Clinical abnormalities of the nipple-areola complex: The role of imaging. Diagn Interv Imaging. Oct 2015;96(10):1033-44. doi:10.1016/j.diii.2015.07.001
  1. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Breast Cancer Version 4.2022. National Comprehensive Cancer Network (NCCN). Updated June 21, 2022. Accessed November 20, 2022.
  2. Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR. J Am Coll Radiol. Mar 2018;15(3 Pt A):408-414. doi:10.1016/j.jacr.2017.11.034
  3. Bahl M, Baker JA, Greenup RA, Ghate SV. Evaluation of Pathologic Nipple Discharge: What is the Added Diagnostic Value of MRI? Ann Surg Oncol. Dec 2015;22 Suppl 3:S435-41. doi:10.1245/s10434- 015-4792-9
  4. Grau AM, Chakravarthy AB, Chugh R. Phyllodes tumors of the breast. Wolters Kluwer. Updated July 14, 2021. Accessed December 20, 2022. the-breast
  5. Li X, Guo H, Cong C, et al. The Potential Value of Texture Analysis Based on Dynamic Contrast- Enhanced MR Images in the Grading of Breast Phyllode Tumors. Front Oncol. 2021;11:745242. doi:10.3389/fonc.2021.745242
  6. Ma W, Guo X, Liu L, et al. Magnetic resonance imaging semantic and quantitative features analyses: an additional diagnostic tool for breast phyllodes tumors. Am J Transl Res. 2020;12(5):2083- 2092.
  7. Lee KA, Talati N, Oudsema R, Steinberger S, Margolies LR. BI-RADS 3: Current and Future Use of Probably Benign. Curr Radiol Rep. 2018;6(2):5-5. doi:10.1007/s40134-018-0266-8
  8. Panigrahi B, Harvey SC, Mullen LA, et al. Characteristics and Outcomes of BI-RADS 3 Lesions on Breast MRI. Clin Breast Cancer. Feb 2019;19(1):e152-e159. doi:10.1016/j.clbc.2018.08.011
  9. Spick C, Bickel H, Polanec SH, Baltzer PA. Breast lesions classified as probably benign (BI-RADS 3) on magnetic resonance imaging: a systematic review and meta-analysis. Eur Radiol. May 2018;28(5):1919- 1928. doi:10.1007/s00330-017-5127-y
  10. Park VY, Kim EK, Kim MJ, Moon HJ, Yoon JH. Breast magnetic resonance imaging for surveillance of women with a personal history of breast cancer: outcomes stratified by interval between definitive surgery and surveillance MR imaging. BMC Cancer. Jan 22 2018;18(1):91. doi:10.1186/s12885-018- 3998-1
  11. Radiology ACo. ACR Appropriateness Criteria® Imaging after Breast Surgery. American College of Radiology. May 9, 2023. Updated New 2022. Accessed March 7, 2023.
  12. Slanetz PJ, Moy L, Baron P, et al. ACR Appropriateness Criteria(®) Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer. J Am Coll Radiol. Nov 2017;14(11s):S462-s475. doi:10.1016/j.jacr.2017.08.037
  13. Lourenco AP, Moy L, Baron P, et al. ACR Appropriateness Criteria(®) Breast Implant Evaluation. J Am Coll Radiol. May 2018;15(5s):S13-s25. doi:10.1016/j.jacr.2018.03.009
  14. Susnik B, Schneider L, Swenson KK, et al. Predictive value of breast magnetic resonance imaging in detecting mammographically occult contralateral breast cancer: Can we target women more likely to have contralateral breast cancer? J Surg Oncol. Jul 2018;118(1):221-227. doi:10.1002/jso.25130
  1. Wong SM, Prakash I, Trabulsi N, et al. Evaluating the Impact of Breast Density on Preoperative MRI in Invasive Lobular Carcinoma. J Am Coll Surg. May 2018;226(5):925-932. doi:10.1016/j.jamcollsurg.2018.01.045
  2. Pennsylvania GAo. The General Assembly of Pennsylvania Senate Bill No. 8 Session of 2023. June 1, 2023. Updated May 1, 2023. Accessed June 1, 2023.
  3. Connecticut General Assembly: § 38a-530. Mandatory coverage for mammography, breast ultrasound and magnetic resonance imaging. Accessed November 20, 2022.
  4. NC Medicaid Division of Health Benefits. Breast Imaging Procedures. Clinical Coverage Policy No: 1K-1; 3.2.1(c). Breast Magnetic Resonance Imaging. Accessed November 20, 2022.
  5. Illinois General Assembly. Senate Bill 0162: 215 ILCS 5/356g (a)(4); 215 ILCS 125/4-6.1 (a)(4); and 305 ILCS 5/5-5 (D) & (E). Effective date January 1, 2020. Accessed November 20, 2022. cNum=162&GAID=15&LegID=&SpecSess=&Session=
  6. Ohio General Assembly. House Bill Number 371 (amendment). Section 1: (A)3; (C)(2)(a); (C)(2)(b). Effective September 23, 2022. Accessed February 25, 2023. https://search-
  7. Panourgias E, Bourgioti C, Koureas A, Koutoulidis V, Metaxas G, Moulopoulos LA. MR imaging features and tumor biomarkers of screen-detected and non-screen detected breast cancers: preliminary results of a comparative study. Clin Imaging. Nov-Dec 2018;52:350-355. doi:10.1016/j.clinimag.2018.08.011
  8. American College of Radiology. ACR Appropriateness Criteria® Evaluation of Nipple Discharge. Updated 2022. Accessed November 30, 2022, 2022.

Coding Section 

Codes Number Description
CPT  77046 (effective 01/01/2019) 

Magnetic resonance imaging, breast, without contrast material; unilateral

  77047 (effective 01/01/2019)

Magnetic resonance imaging, breast, without contrast material; bilateral

  77048 (effective 01/01/2019)

Magnetic resonance imaging, breast, without and with contrast material(s); including computer-aided dtection (CAD real-time lesion detection, characterization and pharmacokinetic analysis) When performed; unilateral 

  77049 (effective 01/01/2019)

Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward     

01012024  NEW POLICY

Complementary Content