Change in prior authorization requirement for diagnosis of dense breasts effective January 1

Beginning January 1, 2025, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will cover breast MRIs for members with a diagnosis of dense breasts without the need for additional criteria to be met.

Effective January 1, prior authorization (PA) will NOT be required for Commercial and Medicare members for a breast MRI in the presence of dense breasts. Carelon Medical Benefits Management (Carelon) manages prior authorization for these services for Blue Cross NC.

If a provider calls Carelon with request for breast MRI and the member has a diagnosis of dense breasts, Carelon will respond that a breast MRI for this diagnosis does not require PA.

For questions contact the provider Blue Line at:

• Commercial: 800-214-4844
• Medicare: 888-296-9790