TRICARE Coverage for Breast Cancer MRI Screening

TRICARE 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 early detection 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 (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 Westr Region coverage for the MRI extends to beneficiaries who meet the ACS criteria and are age 30 and older.

If you believe you may be at high risk, discuss the available breast cancer screening options with your health care provider. Because beneficiaries must fall within specific guidelines, a covered MRI will require your provider to get a prior approval from TriWest. As an added convenience, if you are registered on www.triwest.com, you will receive QuickAlert e-mails delivered directly to your inbox once a referral or authorization has been processed in your name.

The ACS recommends that even if you are eligible for and elect to have an MRI, you continue to receive their regular mammograms even if you elect to have the MRI screening. 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.

Qualified TRICARE beneficiaries who received an MRI screening on or after March 1, 2007, and whose claim was denied may appeal the denial with TriWest. Submit your appeal by mailing a copy of your Explanation of Benefits (EOB) showing the denial and any supporting documents to:

TriWest Healthcare Alliance
Claims Appeals
P.O. Box 86508
Phoenix, AZ 85080