Which payers have published criteria for MRI breast, both sides, without and with contrast (CPT 77049)?

The imaging guidelines used by Aetna, Anthem BCBS, Cigna, Medicare, UnitedHealthcare include criteria that apply to this study. Whether a specific patient's plan requires prior authorization depends on the plan, so confirm on the payer's portal or by phone before scheduling.

Who reviews prior authorization requests for MRI breast, both sides, without and with contrast (CPT 77049)?

Most commercial payers hand imaging reviews to a radiology benefit manager. For the payers tracked here, requests are reviewed using guidelines from eviCore, Carelon, CMS, UnitedHealthcare / eviCore. The request is submitted through that organization's portal rather than the health plan's general line.

What should be in the clinical notes before requesting MRI breast, both sides, without and with contrast (CPT 77049)?

Reviewers look for a recent office visit that documents the symptoms and how long they have lasted, exam findings, results of any earlier imaging, treatments already tried and how the patient responded, and the specific question the study is expected to answer. The diagnosis code on the request should match what the notes describe.

CPT 77049: MRI breast, both sides, without and with contrast - Prior Authorization and Price

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CPT 77049

MRI imaging is performed on both breasts.

MRI Breast

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Payer guidelines that apply

Payer	Reviewed using	Guideline	Sections
Aetna	eviCore	Breast Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026	18 that name this code
Anthem BCBS	Carelon	Oncologic imaging effective Apr 4, 2026 Imaging of the chest effective Apr 4, 2026	7 that name this code
Cigna	eviCore	Breast Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026 Pediatric and Special Populations Oncology Imaging Guidelines 2.0.2026, effective Sep 1, 2026	19 that name this code
Medicare	CMS	NCD 220.2: Magnetic Resonance Imaging effective Apr 10, 2018 L33585: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (Wellpoint Federal) effective Apr 1, 2026 L33950: Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography (CGS Administrators) effective Dec 4, 2025	3 that name this code
Original Medicare does not run a prior authorization program for outpatient imaging; claims are judged against the coverage policies above. Medicare Advantage plans set their own prior authorization rules.
UnitedHealthcare	UnitedHealthcare / eviCore	Commercial and Exchange Cardiovascular and Radiology Imaging Guidelines 09.2026, effective Sep 1, 2026	18 that name this code

Guidelines collected from the payers' published documents on September 29, 2026. Payers revise these documents during the year. Open the guideline link to confirm the current version before you submit.

Conditions the guidelines address for this study

These are the clinical situations where payer guidelines discuss MRI breast, both sides, without and with contrast. Each has its own criteria for when the study is considered appropriate.

Alternative Breast Imaging Approaches Aetna · Cigna · UnitedHealthcare
Breast Evaluation in Pregnant or Lactating Females Aetna · Cigna · UnitedHealthcare
Malignant Phyllodes Tumor/Cystosarcoma Phyllodes Aetna · Cigna · UnitedHealthcare
MRI Breast Coding Aetna · Cigna · UnitedHealthcare
Nipple Discharge/Galactorrhea Aetna · Cigna · UnitedHealthcare
Nipple Inversion/Retraction Aetna · Cigna · UnitedHealthcare
Skin Changes Aetna · Cigna · UnitedHealthcare
Transgender Breast Cancer Supplemental Screening Aetna · Cigna · UnitedHealthcare
Breast Cancer Aetna · Anthem BCBS · Cigna · UnitedHealthcare
Sarcomas – Bone, Soft Tissue, and GIST Aetna · Cigna · UnitedHealthcare
Long Term Pediatric Cancer Survivors Aetna · Cigna · UnitedHealthcare
Metastatic Cancer, Carcinoma of Unknown Primary Site, and Other Types of Cancer Aetna · Cigna · UnitedHealthcare
Non-Hodgkin Lymphomas Aetna · Cigna · UnitedHealthcare
Screening Imaging in Cancer Predisposition Syndromes Aetna · Cigna · UnitedHealthcare
Breast cancer screening Anthem BCBS
Breast Imaging Mammography/Breast Echography (Sonography)/Breast MRI/Ductography Medicare
Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography Medicare
Breast implant rupture Anthem BCBS
Cancer Screening Anthem BCBS
Cancer screening, not otherwise specified Anthem BCBS
Histiocytic Neoplasms Anthem BCBS
Magnetic Resonance Imaging Medicare
Neuroendocrine Tumors Anthem BCBS

Typical price

Commercial insurance, median

$1,630

Middle half of rates: $721 to $2,546

Medicare, physician fee schedule

$341

National, non-facility

Commercial figures come from negotiated rates published by 571 hospitals; Medicare figures from CMS fee schedules. Rates vary widely by hospital and plan. Pricing data from CenterIQ.

Get notified when the rules for this study change

Payers update imaging guidelines several times a year. We will email you when the criteria for MRI breast, both sides, without and with contrast change.

CPT 77049: MRI breast, both sides, without and with contrast - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

Imaging CPT Code Coverage Lookup

Quick Access - Common Imaging CPT Codes

CT

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MRA

PET

CPT 77049: MRI breast, both sides, without and with contrast - Prior Authorization and Price

Payer guidelines that apply

Conditions the guidelines address for this study

Typical price

Get notified when the rules for this study change

Frequently asked questions

Related studies

Imaging CPT Code Coverage Lookup

Quick Access - Common Imaging CPT Codes

CT

MRI

MRA

PET