How to Appeal a UnitedHealthcare Breast Imaging for Screening and Diagnosing Cancer Denial
UnitedHealthcare decides coverage for Breast Imaging for Screening and Diagnosing Cancer under policy 2026T0375LL. The most effective appeal shows, point by point, that you meet UnitedHealthcare's own criteria below.
What UnitedHealthcare requires for coverage
UnitedHealthcare considers Breast Imaging for Screening and Diagnosing Cancer medically necessary when the following criteria (from 2026T0375LL) are met:
- MRI of the breast for individuals high risk: heterogeneously dense breasts (Category C) or extremely dense breasts (Category D) (screening beginning at age 40)
- Prior thoracic radiation therapy between ages 10-30 (screening starting at age 25 or 8 years after treatment, whichever is later)
- Lifetime risk >= 20% as defined by models (Gail, Claus, Tyrer-Cuzick, BRCAPRO) (screening beginning at age 40)
- Personal history of breast cancer (not treated with bilateral mastectomy)
- Personal history of BRCA1 or BRCA2 (screening beginning at age 25)
- Personal history of ATM, CDH1, CHEK2, NF1, PALB2, PTEN/Cowden, STK11/Peutz-Jehgers (screening beginning at age 30)
- Personal history of TP53/Li-Fraumeni (screening beginning at age 20)
- Personal history of BARD1, RAD51C, RAD51D (screening beginning at age 40)
- Family history: at least one first-degree relative with BRCA1/BRCA2 mutation (screening at age 40)
- Family history: first-degree relative with TP53 or PTEN gene mutation
- Family history: at least two first-degree relatives with breast or ovarian cancer (screening at age 40)
- Family history: one first-degree relative with bilateral breast cancer or both breast and ovarian cancer (screening at age 40)
- Family history: first- or second-degree male relative diagnosed with breast cancer (screening at age 40)
Covered procedure codes
How to appeal this denial
Frame your appeal around the specific criterion you satisfy. Quote the 2026T0375LL language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that UnitedHealthcare either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.
Source: UnitedHealthcare medical policy 2026T0375LL — view the published policy.