Magnetic Resonance Imaging (MRI) of the Breast — CPB 0105 | AETNA Coverage Update

Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Magnetic Resonance Imaging (MRI) of the Breast
Policy Code	CPB 0105
Change Type	Modified
Effective Date	March 19, 2026
Impact Level	High
Specialties Affected	Radiology, Breast Surgery, Oncology, Ob/Gyn, Plastic Surgery
Key Action	Audit your breast MRI prior authorization workflows and confirm all claims include a qualifying recent mammogram or sonogram on file before March 19, 2026

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Aetna Breast MRI Coverage Criteria and Medical Necessity Requirements 2026

The foundational rule in this coverage policy hasn't changed, but it's worth stating plainly because it trips up a lot of claims: before Aetna will cover CPT 77046, 77047, 77048, or 77049, the member must have had a conventional mammogram or breast sonogram within the past year. That prerequisite applies across almost every diagnostic indication listed below.

The only exception is the high-risk screening pathway for women under 30, where Aetna waives the mammography requirement. Outside of that, no recent mammogram or sonogram means no covered breast MRI — and your prior authorization request will hit a wall before it even reaches clinical review.

Diagnostic Medical Necessity: The 13 Covered Indications

Aetna recognizes 13 categories where breast MRI meets medical necessity for diagnostic use. Here's what each one requires.

Chest radiation history. Members who received chest radiation between ages 10 and 30 — for conditions like Hodgkin disease or Wilms tumor — qualify. The MRI must have a plausible effect on clinical management.

Neoadjuvant chemotherapy staging. Aetna covers breast MRI to assess tumor location, size, and extent before and after neoadjuvant chemotherapy in locally advanced breast cancer. The clinical purpose is determining eligibility for breast conservation therapy.

Implant rupture detection. Coverage applies to symptomatic members only. Asymptomatic implant surveillance is a different conversation — and not a covered one here.

Post-mastectomy recurrence detection. Members who have had mastectomy and breast reconstruction with an implant qualify when there's suspicion of local tumor recurrence.

Dense breast or scar tissue obstruction. If combined mammography and ultrasonography can't adequately evaluate a member because of radiographically dense breasts or old surgical scar tissue, breast MRI is covered to detect local tumor recurrence.

Positive margin after incomplete lumpectomy. Coverage applies when the member wants breast conservation and re-excision is planned. The MRI maps residual cancer in the recently post-operative breast.

MRI-guided needle biopsy localization. When a suspicious lesion is visible only on contrast-enhanced MRI — not on mammography or ultrasound — Aetna covers MRI to guide localization for needle biopsy. CPT 19085, 19086, 19287, 19288, and HCPCS C7502 all tie into this indication for the biopsy and localization procedures themselves.

Occult primary breast cancer. When adenocarcinoma presents as axillary node or distant metastasis without a focal finding on physical exam, mammography, or ultrasound, MRI is covered to locate the primary site.

Tumor mapping for specific diagnoses. Aetna covers MRI to map primary tumors and identify multicentric disease for members with any of the following: multifocal or multicentric breast cancer, pre-neoadjuvant systemic therapy staging, adenocarcinoma in axillary lymph node without identified breast primary, invasive lobular carcinoma, or Paget's disease of the breast. Contralateral breast examination is also covered for these same five conditions.

Nipple symptom characterization. When nipple retraction or unilateral bloody or clear nipple drainage can't be resolved by ultrasound, mammography, and physical exam, MRI qualifies for lesion characterization.

Post-conservation therapy surveillance. After breast conservation therapy, members with suspicious clinical or imaging findings that remain indeterminate after full mammographic and sonographic evaluation qualify for MRI.

Inconclusive mammography or ultrasound. When mammography or ultrasound findings are inconclusive or conflicting — and the finding is not a discrete palpable mass — MRI is covered for further evaluation.

High-Risk Screening: The Second Coverage Pathway

Separate from the diagnostic indications, Aetna covers breast MRI as a screening adjunct to mammography for women at high genetic risk. This pathway requires mammography within the past year, except for women under 30.

Qualifying genetic risk factors include: PTEN gene mutations (Cowden and Bannayan-Riley-Ruvalcaba syndromes, with screening beginning at age 30), TP53 gene mutations (Li-Fraumeni syndrome), and other defined hereditary breast cancer syndromes. The policy summary was truncated here, so the full list of qualifying gene mutations covers additional markers — confirm the complete criteria in the full CPB 0105 text before submitting screening claims.

The real-world reimbursement issue with this pathway is documentation. Aetna wants proof of genetic risk, not just clinical suspicion. That means genetic counseling notes, genetic test results, or documented first-degree relative carrier status — all in the chart before you seek prior authorization.

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Aetna Breast MRI Exclusions and Non-Covered Indications

The clearest exclusion in this policy is quantitative MRI tissue composition analysis. CPT 0697T and 0698T — which cover quantitative MRI for analysis of fat, iron, water content, and similar tissue composition metrics — are explicitly not covered for the indications listed in CPB 0105.

These codes are newer Category III codes, and Aetna's position here is consistent with how most major payers treat them: experimental, not covered. Don't bill 0697T or 0698T expecting reimbursement on an Aetna breast MRI claim. You'll get a claim denial and no viable appeal path under this policy.

Asymptomatic implant surveillance also falls outside covered indications. The policy covers implant rupture detection for symptomatic members. Routine screening MRI of intact implants without symptoms isn't a qualifying indication.

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Coverage Indications at a Glance

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Aetna Breast MRI Billing Guidelines and Action Items 2026

This policy has more moving parts than most imaging policies. Here's what your billing team needs to do before March 19, 2026.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Breast MRI Under CPB 0105

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
C7502	HCPCS	Percutaneous breast biopsies using magnetic resonance guidance, with placement of breast localization device(s)
C8903	HCPCS	Magnetic resonance imaging with contrast, breast; unilateral

Not Covered / Experimental CPT Codes

Code	Type	Description	Reason Copy
0697T	CPT	Quantitative MRI for analysis of tissue composition (e.g., fat, iron, water content), including image acquisition, data preparation, calculations, and report	Explicitly not covered for indications listed in CPB 0105
0698T	CPT	Quantitative MRI for analysis of tissue composition, each additional organ system (add-on)	Explicitly not covered for indications listed in CPB 0105