Is Preauth Required? Preauthorization is required for breast MRI if the patient has positive axillary nodes but no known primary, has rupture of a breast implant, or is being used to determine the extent of disease in a patient with known malignancy prior to treatment (to assure confinement to one segment of the breast).
Will the claim be denied? Medicare Part B covers MRI services for breast cancer, so a claim for MRI services for breast cancer should not be denied.
When is the following treatment medically necessary for the condition specified? MRI is considered medically necessary for breast cancer when it is used to determine the extent of the disease in patients with known malignancy, prior to treatment (to assure confinement to one segment of the breast). It can also be used in cases where diagnosis is inconclusive, even after standard work-up, to evaluate the post-operative patient when scar tissue cannot be differentiated from tumors, and for patients with positive axillary nodes but no known primary.
What would make the following treatment considered medically necessary? MRI is not considered medically necessary for the diagnosis or treatment of breast cancer. According to the CMS National Coverage Policy, Title XVIII of the Social Security Act (SSA) §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Therefore, MRI is not considered medically necessary for breast cancer.
What are the relevant codes for the treatment? CPT code 77054 (Mammary Ductogram or Galactogram, Multiple Ducts, Radiological Supervision and Interpretation) and CPT code C8903 (Magnetic Resonance Imaging With Contrast, Breast; Unilateral) may be used for billing and coding of MRI for breast cancer. ICD-10-CM code C50.011 (Malignant Neoplasm of Nipple and Areola, Right Female Breast) may be used to support medical necessity.
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