Bilateral Breast Magnetic Resonance Imaging denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 42-year-old female who had an abnormal screening mammogram in April 2006 which led to ultrasound of the breasts in May 2006. The ultrasound showed multiple cysts bilaterally with the largest cyst in the right breast measuring up to 1.4cm. In addition, within the left breast a 5mm hypoechoic defect with internal echoes was found at the 8 o’clock position near the areola. This was felt to be either a complicated cyst or a solid mass and biopsy was recommended. The patient has a family history of breast cancer with a younger sister diagnosed at age 35, the paternal grandmother having a mastectomy at age 35 and the maternal grandmother dying of breast cancer at age 63. The patient was evaluated by a surgeon who ordered breast MRI which was performed in August 2006. The study showed cysts and proliferative changes with no evidence for malignancy.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI).Contrast-enhanced breast MRI is more sensitive for the detection of breast cancer in the high-risk population. Overall, contrast-enhanced MRI has greater sensitivity than mammography and ultrasound and can be beneficial in specific clinical settings. As noted by a clinical study, screening breast MRI is recommended in women with a lifetime risk of greater than 20%, women with BRCA gene mutations, and their untested first-degree relatives as well as other high-risk populations. These high populations include female patients with a history of thoracic or upper abdominal radiation therapy at an early age.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). Findings: The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. This patient does not meet the criteria for being at high risk for developing breast cancer, which is defined as having a 20-25% likelihood of developing the disease. Per the records, she has not had BRCA testing, and the occurrence of breast malignancy in aunts and a cousin does not constitute a greater than 20-25% risk of breast cancer. Further, her prior mammograms have not detected any abnormalities suggestive of tumor. MRI studies of the breast are highly sensitive but have a relatively low level of specificity.

Findings: The physician reviewer found that a patient has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of a palpable mass in a patient greater than 40 years of age, a diagnostic mammography is the first step, followed by sonography. Rarely, if there is a strong continued clinical suspicion for a palpable lump, despite negative diagnostic mammography and sonography, an MRI may be indicated.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Bilateral Breast Magnetic Resonance Imaging, then check the rights and deadlines that apply to your plan.