Breast Cancer Risk: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. In the medical literature, the largest studies reporting on the outcomes of multigene testing indicate that among female patients tested in clinical settings, about 5-10% have a BRCA1 or BRCA2 mutation, and about 4-7% have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may be associated with increased risks for these cancers. Panel testing is now considered a standard of care in this clinical setting. This patient has three close relatives with malignancies that could be familial and suspicious for a BRCA mutation on the paternal side. This meets the National Comprehensive Cancer Network (NCCN) guidelines for BRCA testing. Panel testing is now considered within the standard of care.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of breasts (CPT 77046). The American College of Radiology (ACR) recommends screening breast MRI in women at high risk for breast cancer on the basis of family history or genetic predisposition. The ACR appropriateness criteria for breast cancer screening categorizes women with 20% or greater lifetime risk of breast cancer as high-risk. For such women, breast MRI without and with intravenous contrast is usually appropriate. Spick and colleagues found that short-term follow-up MRI at intervals of six, twelve, and 24 months of MRI-detected probably benign (BI-RADS 3) lesions remained a strong tool with which to detect suspicious lesions, and monitor interval changes in size, morphology, or enhancement that may be indicative of malignancy.

Where the denial was upheld

A 36-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mammogram and a breast magnetic resonance imaging (MRI) every 6 months for evaluation of the enrollee’s risk for breast cancer. Findings: Two physician reviewers found that the patient has a strong family history of breast cancer in her sister who was diagnosed with invasive ductal breast cancer at the age of 30. The patient has had prior mammograms and breast MRI studies that have shown extremely dense breast tissue. BRCA testing was negative. The patient had a screening breast MRI on and is requesting reimbursement for this study as well as future coverage for a mammogram and breast MRI every 6 months. The American Cancer Society (ACS) does not advocate for screening breast MRI for patients with dense breast tissue.

The patient has requested authorization and coverage for double mastectomy. A mastectomy, defined as the complete removal of the breast tissue, is a surgical option for patients diagnosed with breast cancer as well as a prophylaxis to reduce the risk of breast cancer in high-risk women, a study found that, “prophylactic mastectomy generally occurs in two different patient populations: (1) high-risk women without breast cancer who undergo bilateral prophylactic mastectomy (BPM) to reduce their risk of developing breast cancer and (2) women with unilateral breast cancer who choose contralateral prophylactic mastectomy (CPM) to prevent cancer in the contralateral breast.” Most studies conclude that BPM is not indicated for women without quantifiable high-risk demonstrated with a strong family history and/or findings on breast biopsy known to increase risk of future invasive cancer such as a…

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for breast cancer risk was denied, the published record says the denial is worth fighting.