CMS Percutaneous Image-Guided Breast Biopsy Coverage Policy Updated for 2026 (NCD 272)

CMS has issued a modification to National Coverage Determination 272, governing Medicare coverage for percutaneous image-guided breast biopsy. This update affects how facilities and physician practices document medical necessity and submit claims for both non-palpable and palpable breast lesion biopsies performed under ultrasound or stereotactic guidance. Billing teams across radiology, surgery, and women's health need to review their documentation workflows now—before the March 12, 2026 effective date.

What NCD 272 Covers: CMS Medicare Criteria for Image-Guided Breast Biopsy

Percutaneous image-guided breast biopsy is a minimally invasive procedure in which a tissue sample is obtained through a small skin incision using real-time imaging guidance—either ultrasound or stereotactic (mammography-based) systems. It is used as an alternative to open surgical biopsy when a radiographic abnormality is identified and tissue sampling is required for diagnosis.

The Centers for Medicare & Medicaid Services established coverage for this procedure effective January 1, 2003 under NCD 272, and the 2026 modification carries forward the core coverage framework. The policy applies across four benefit categories: Ambulatory Surgical Center Facility Services, Inpatient Hospital Services, Outpatient Hospital Services Incident to a Physician's Service, and Physicians' Services.

The foundation of medical necessity documentation under this NCD is the Breast Imaging Reporting and Data System (BIRADS), developed by the American College of Radiology. BIRADS provides a standardized grading system that radiologists use when interpreting mammograms, and CMS has anchored coverage eligibility directly to these grades.

CMS BIRADS Grade Requirements for Medicare Coverage

Understanding the BIRADS scale is non-negotiable for any billing team submitting claims under NCD 272. Here's the full grading structure as referenced in the policy:

Medicare coverage under NCD 272 is only available when the radiographic abnormality is graded BIRADS III, IV, or V. Lesions graded BIRADS I or II do not meet coverage criteria, and claims submitted without documented BIRADS grading at the qualifying level will be vulnerable to denial.

Non-Palpable vs. Palpable Breast Lesions: How CMS Distinguishes Coverage

NCD 272 draws a clear line between two clinical scenarios, and your documentation must address which situation applies.

Non-Palpable Breast Lesions

Medicare covers percutaneous image-guided breast biopsy—using either stereotactic or ultrasound imaging—for radiographic abnormalities that are non-palpable and graded BIRADS III, IV, or V. The non-palpable designation means the lesion cannot be felt on physical examination and was identified through imaging. This is the more straightforward coverage pathway, provided the BIRADS grade is documented.

Palpable Breast Lesions

Coverage also extends to palpable lesions—those that can be detected on physical exam—but only when the lesion is determined to be difficult to biopsy using palpation alone. This is a more nuanced determination, and CMS explicitly delegates discretion here to Medicare Administrative Contractors (MACs). Your regional MAC has the authority to define what types of palpable lesions qualify as difficult to biopsy by palpation.

This MAC-level discretion is a significant compliance point. A palpable lesion biopsy that clears coverage in one MAC jurisdiction may not clear it in another. Billing teams operating across multiple regions—or facilities that recently changed MAC jurisdiction—must verify their specific contractor's published guidance on this criterion.

Prior Authorization and Experimental Designations Under NCD 272

The policy does not specify a prior authorization requirement within the NCD itself. However, given that MACs retain discretion over palpable lesion determinations, it is advisable to check your contractor's Local Coverage Determinations (LCDs) for any additional prior authorization or pre-certification steps they may impose at the local level.

There are no experimental or investigational designations within NCD 272. Both stereotactic and ultrasound guidance modalities are recognized as covered approaches under the same coverage criteria.

Affected Codes

The policy document for NCD 272 does not list specific CPT or HCPCS codes within its text. CMS has not enumerated procedure codes directly in this NCD. Billing teams should reference their MAC's corresponding LCD and associated Billing and Coding Article for the specific CPT codes applicable to percutaneous image-guided breast biopsy procedures in their jurisdiction. There are no ICD-10-CM diagnosis codes listed in this policy document.

No covered or non-covered code tables can be constructed from this policy data—fabricating codes here would create compliance risk. Contact your MAC or consult a current coding reference to identify the applicable procedure codes.

What Your Billing Team Should Do