TRICARE Coverage for Breast Cancer MRI Screening

TRICARE now covers magnetic resonance imaging (MRI) screenings for beneficiaries within the American Cancer Society’s (ACS) guidelines for a high risk of breast cancer. The TRICARE Management Activity (TMA) estimates that breast cancer is the third most common cancer among TRICARE beneficiaries.

Screening is used to identify cancer before any symptoms are seen because treatment can be more effective if started early. Recent ACS studies have shown that screening only catches about 61 percent of breast cancers.

ACS guidelines suggest an MRI for women who have:

• BRCA1 or BRCA2 gene mutation
• A first degree relative (e.g., parent, sibling or child) with BRCA1 or BRCA2 mutation, even if the beneficiary herself is untested
• A lifetime risk calculated at 20 percent or greater as defined by BRCAPRO or another model largely dependent on family history
• A history of chest radiation between the ages of 10 and 30
• A history of Li­Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba (macrocephaly) syndromes or a first-degree relative with any of those syndromes

TRICARE coverage for the MRI extends to beneficiaries who meet the ACS criteria and are:

• TRICARE Prime beneficiaries age 30 and older
• TRICARE Standard and Extra beneficiaries age 35 and older

If you believe a TRICARE beneficiary may be at high risk, please discuss the available breast cancer screening options with them. Breast cancer MRIs require prior authorization for all TRICARE beneficiaries in programs administered by TriWest, including Prime, TRICARE Prime Remote, Standard, Extra and TRICARE Reserve Select.

The ACS recommends that even if a TRICARE beneficiary is eligible for and elects to have an MRI, she should continue to receive her regular mammograms. TRICARE covers an annual mammogram for women at high risk of breast cancer (a history of breast cancer in a first degree relative) who are age 35 and older and all women age 39 and older.

TRICARE coverage of breast MRIs is retroactive to March 1, 2007. Anyone who meets the criteria for a breast MRI is covered. If a qualified beneficiary received a breast MRI on or after March 1, 2007, and the claim was denied, the provider can contact TriWest and ask to have the claim reconsidered.