Breast Lesion: 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 breast magnetic resonance imaging (MRI) provided for evaluation of the enrollee, who had an abnormality on a mammogram. Findings: The 3 physician reviewers found that there is sufficient support for the services at issue in this clinical setting. In this case, mammograms clearly showed a new area of abnormality. However, the problem was that it was only visualized on one view, and could not be localized on the second view. The sonogram that was performed did not help resolve the issue. This patient’s mammographic findings necessitated further work-up. Breast MRI was needed for localization and/or confirmation. Thus, breast MRI provided was likely to have been of greater benefit than other methods of evaluating this patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breasts. Findings: Two of the three physician reviewers found breast MRI has an important role in both screening and diagnostic settings. There are multiple clinical considerations in which MRI has become widely used. These include areas of asymmetry, architectural distortion, and distinguishing tumor recurrence versus scarring. Breast MRI may be a useful adjunctive tool when conventional imaging findings are equivocal, as in this clinical setting. The Health Plan has noted that an MRI should not replace a biopsy in clear-cut masses. However, in this patient’s case, it is unclear whether she actually has a mass.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the breasts. Contrast enhanced breast MRI is a highly sensitive examination helpful in identifying abnormalities that may be are occult on mammography and ultrasound. The indications for breast MRI include high risk screening, new diagnosis of breast cancer to evaluate for additional sites of disease, and patients with positive margins after lumpectomy. Additional indications include evaluation of response to chemotherapy prior to surgery, evaluation for breast cancer recurrence, evaluation of metastatic cancer of an unknown primary source, and when mammographic or ultrasound findings are inconclusive.

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that one of the primary arguments supporting the use of tomosynthesis is that it reduces the frequency of callbacks for further evaluation of a suspected breast lesion. However, on occasion, it is necessary to obtain further images, and it is not unusual to perform additional imaging as well as a sonogram as in this clinical setting. In this case, the initial screening mammogram included tomosynthesis. While an initial tomosynthesis was indicated and successful in detecting an otherwise occult mass, a second tomosynthesis within a short period of time was not likely to yield additional data.

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 lesion was denied, the published record says the denial is worth fighting.