TL;DR: Aetna, a CVS Health company, modified CPB 0105 governing breast MRI coverage, effective September 26, 2025. If your team bills CPT 77046, 77047, 77048, or 77049, review every indication in this update before your next claim goes out.
Aetna breast MRI coverage policy CPB 0105 is one of the more detailed clinical benefit policies in Aetna's library — 13 diagnostic indications, a separate high-risk screening pathway, and a hard line on what's experimental. The September 26, 2025 modification touches the medical necessity criteria across multiple clinical scenarios. Two CPT codes (0697T and 0698T for quantitative MRI tissue analysis) are explicitly not covered. Your billing team needs to know which indications pass and which ones don't before the effective date.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Magnetic Resonance Imaging (MRI) of the Breast |
| Policy Code | CPB 0105 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Radiology, Breast Surgery, Oncology, OB/GYN, Genetic Counseling |
| Key Action | Audit all active breast MRI orders against the updated 13-indication diagnostic criteria and high-risk screening rules before submitting claims under CPT 77046–77049 |
Aetna Breast MRI Coverage Criteria and Medical Necessity Requirements 2025
Aetna's coverage policy splits breast MRI into two distinct pathways: diagnostic and high-risk screening. The requirements differ. Confusing them is the fastest way to a claim denial.
The diagnostic pathway requires a recent conventional mammogram or breast sonogram within the past year before MRI is considered medically necessary. That's your first documentation checkpoint. If that prior imaging isn't in the record, Aetna has grounds to deny before it even evaluates the clinical indication.
Thirteen specific diagnostic indications qualify under this pathway. Each one is its own coverage test. Meeting one is enough — but you have to document which one applies.
The 13 Covered Diagnostic Indications
| # | Covered Indication |
|---|---|
| 1 | Radiation to the chest between ages 10 and 30 — treatment for Hodgkin disease, Wilms tumors, or similar. The age window matters. Document it. |
| 2 | Neoadjuvant chemotherapy assessment — tumor location, size, and extent before and/or after chemotherapy in locally advanced breast cancer, for breast conservation therapy eligibility. CPT 77048 or 77049 (with contrast) is the right code here. |
| 3 | Implant rupture — symptomatic members only. Asymptomatic implant evaluation doesn't qualify under this indication. CPT 77046 or 77047 (without contrast) may apply depending on protocol. |
| 4 | Post-mastectomy local tumor recurrence with implant reconstruction. Aetna covers this specifically for members who had mastectomy followed by implant-based reconstruction. |
| 5 | Local tumor recurrence with dense breasts or scar tissue — when combined mammography and ultrasonography can't give a clear picture. |
| 6 | Residual cancer after incomplete lumpectomy with positive margins — only when the member still wants breast conservation and re-excision is planned. This one has two conditions. Both need documentation. |
| 7 | MRI-guided needle biopsy localization — when the suspicious lesion is visible only on contrast-enhanced MRI and can't be seen on mammography or ultrasound. CPT 19085 and 19086 are the add-on localization codes tied to this indication. |
| 8 | Occult primary breast cancer — adenocarcinoma found in axillary node or distant metastasis without a primary site identified on physical exam, mammography, or ultrasound. |
| 9 | Tumor extent mapping and multicentric disease — applies to five specific presentations: multifocal or multicentric breast cancer, before neoadjuvant systemic therapy, adenocarcinoma in axillary lymph node without an identified breast primary, invasive lobular carcinoma, and Paget's disease of the breast. |
| 10 | Contralateral breast examination — same five presentations as indication nine. This is a separate indication. Bill it separately with the correct ICD-10 linkage. |
| 11 | Lesion characterization for nipple symptoms — nipple retraction or unilateral nipple discharge (bloody or clear) when ultrasound, mammography, and physical exam are all inconclusive. |
| 12 | Post-breast-conservation therapy with suspicious findings — when mammography and sonography findings remain indeterminate after full evaluation. |
| 13 | Inconclusive or conflicting mammography/ultrasound findings — when findings are not a discrete palpable mass. That qualifier matters. A palpable mass is a different clinical scenario. |
The high-risk screening pathway is separate and requires prior mammography within the past year. The exception: women under 30 don't need a prior mammogram. This pathway covers members with high genetic risk, including BRCA1, BRCA2, PALB2, PTEN (Cowden syndrome), TP53 (Li-Fraumeni syndrome), and STK11/Peutz-Jeghers syndrome mutations. It also covers first-degree relatives of known mutation carriers and women who have received genetic counseling and been assessed at elevated lifetime risk.
Prior authorization requirements for breast MRI under Aetna vary by plan. Check the member's specific plan before submitting. High-risk screening MRIs and diagnostic MRIs often have different prior auth pathways.
Aetna Breast MRI Exclusions and Non-Covered Indications
Two CPT codes are explicitly not covered under this coverage policy for any indication listed in CPB 0105.
CPT 0697T and 0698T — quantitative MRI for tissue composition analysis (fat, iron, water content). Aetna considers these experimental and investigational for breast applications. If your radiologists are using quantitative MRI protocols and billing these codes alongside 77046–77049, expect denial. This is a hard exclusion, not a gray area.
The policy also excludes breast MRI when the prior imaging requirement isn't met. No recent mammogram or sonogram on record means the diagnostic pathway doesn't open, regardless of clinical indication. That's a documentation failure, not a clinical one — and it's avoidable.
Asymptomatic implant surveillance (absent a specific clinical concern) doesn't meet medical necessity under indication three. Symptom documentation is required.
Coverage Indications at a Glance
| Indication | Status | Relevant CPT Codes | Notes |
|---|---|---|---|
| Chest radiation (ages 10–30) | Covered | 77046, 77047, 77048, 77049 | Requires recent mammogram/sonogram |
| Neoadjuvant chemo assessment | Covered | 77048, 77049 | Contrast required; locally advanced breast cancer |
| Implant rupture — symptomatic | Covered | 77046, 77047 | Symptom documentation required; asymptomatic not covered |
| Post-mastectomy recurrence with implant | Covered | 77046, 77047, 77048, 77049 | Mastectomy + implant reconstruction required |
| Recurrence with dense breasts or scar tissue | Covered | 77046, 77047, 77048, 77049 | Mammography/ultrasound must be compromised |
| Residual cancer, incomplete lumpectomy, positive margins | Covered | 77048, 77049 | Patient must still want breast conservation; re-excision planned |
| MRI-guided biopsy localization | Covered | 19085, 19086, 19287, 19288 | Lesion visible only on contrast MRI |
| Occult primary breast cancer | Covered | 77048, 77049 | Axillary node or distant metastasis; no primary on mammogram/ultrasound |
| Tumor extent mapping / multicentric disease | Covered | 77048, 77049 | 5 specific presentations (see policy) |
| Contralateral breast exam | Covered | 77046, 77047, 77048, 77049 | Same 5 presentations as extent mapping |
| Nipple symptom characterization | Covered | 77048, 77049 | All other imaging and exam inconclusive |
| Post-breast-conservation therapy surveillance | Covered | 77046, 77047, 77048, 77049 | Suspicious findings; full mammo/sono eval done |
| Inconclusive mammography/ultrasound | Covered | 77046, 77047, 77048, 77049 | Not a discrete palpable mass |
| High-risk screening (BRCA1/2, PALB2, PTEN, TP53, STK11) | Covered | 77046, 77047, 77048, 77049 | Mammography within past year (except under age 30) |
| Quantitative MRI tissue composition (0697T, 0698T) | Not Covered | 0697T, 0698T | Experimental per CPB 0105 |
| Asymptomatic implant surveillance | Not Covered | — | No qualifying indication without symptoms |
Aetna Breast MRI Billing Guidelines and Action Items 2025
The effective date is September 26, 2025. Here's what to do before that date — and what to keep doing after.
| # | Action Item |
|---|---|
| 1 | Audit your open breast MRI orders against the 13-indication checklist. For every pending order, confirm which indication applies and whether the required prior mammogram or sonogram is on file. Missing prior imaging is an automatic denial risk under this coverage policy. |
| 2 | Remove CPT 0697T and 0698T from any breast MRI charge capture templates. These codes are not covered under CPB 0105. If your radiology team bills quantitative MRI protocols, flag this now. Retrain whoever builds your order sets. |
| 3 | Separate your documentation for indication 9 (tumor extent mapping) and indication 10 (contralateral breast exam). These are distinct indications with the same five clinical presentations. If both breasts are being imaged for one of those presentations, you need separate ICD-10 linkage and documentation for each side. |
| 4 | Verify prior authorization requirements for each member's plan before scheduling. Aetna breast MRI reimbursement varies by plan type. Diagnostic and screening MRIs may route through different PA pathways. Don't assume a prior auth for a diagnostic indication covers a screening MRI, or vice versa. |
| 5 | Check age and mutation documentation for high-risk screening claims. PTEN screening starts at age 30. TP53 starts at age 20 (or the age of earliest diagnosed breast cancer in the family). PALB2 starts at age 30. If you're billing screening MRI for a member under the applicable threshold, you need a clear documented exception or the claim will fail medical necessity review. |
| 6 | Update your ICD-10 mapping for the five multicentric/lobular presentations. Invasive lobular carcinoma, Paget's disease, multifocal breast cancer, axillary adenocarcinoma without identified primary, and pre-neoadjuvant therapy staging all appear in both indication 9 and 10. Make sure your diagnosis codes are specific. Vague ICD-10 coding on these claims is a top reason for medical necessity denials. |
| 7 | If you're unsure how this policy applies to a specific patient's plan or clinical scenario, loop in your compliance officer before September 26, 2025. The interaction between plan-level exclusions and CPB 0105 criteria can produce outcomes that aren't obvious from the policy text alone. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Breast MRI Under CPB 0105
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Description |
|---|---|
| 77046 | MRI, breast, without contrast material, unilateral |
| 77047 | MRI, breast, without contrast material, bilateral |
| 77048 | MRI, breast, without and with contrast material(s), including CAD, unilateral |
| 77049 | MRI, breast, without and with contrast material(s), including CAD, bilateral |
| 19085 | Biopsy, breast, with placement of breast localization device(s), when performed; first lesion, including MRI guidance |
| 19086 | Biopsy, breast, with placement of breast localization device(s); each additional lesion, including MRI guidance |
| 19287 | Placement of breast localization device(s), first lesion, including MRI guidance |
| 19288 | Placement of breast localization device(s); each additional lesion, including MRI guidance |
Not Covered / Experimental Codes
| Code | Description | Reason |
|---|---|---|
| 0697T | Quantitative MRI for tissue composition analysis (e.g., fat, iron, water content), including CAD software, first study | |
| 0698T | Quantitative MRI for tissue composition analysis (e.g., fat, iron, water content), including CAD software, each additional study | Experimental/investigational per CPB 0105 — not covered for any breast indication |
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