Bilateral Breast MRI denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 59-year-old female who was diagnosed with infiltrating lobular carcinoma of the right breast in June 2006. Her surgeon has requested bilateral MRI of the breasts to determine the extent of the disease within the right breast and to evaluate for synchronous tumor within the left breast. The surgeon has submitted a request for authorization of bilateral breast MRIs prior to surgery. The Health Plan denied the request based upon a determination that the diagnostic procedure is experimental/ investigation in this clinical setting.There are several established indications for MRI screening of the breast with malignant disease which include preoperative evaluation of the extent of the cancer, postoperative assessment of residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, screening of hig…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI). The American College of Radiology (ACR) appropriateness criteria for breast cancer screening indicate that breast MRI, with and without intravenous (IV) contrast, is usually appropriate for supplemental breast cancer screening in high-risk patients with dense breasts. In high-risk patients, the sensitivity of a mammogram is approximately 30%, compared to the sensitivity of an MRI alone which is 87-96%. The combination of mammography and MRI yields 100% sensitivity compared with 44-48% sensitivity of combined mammography and ultrasound. Additionally, the type of carcinoma detected on MRI compared with mammography may differ, which may potentially change the patient’s treatment plan.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral magnetic resonance imaging of breast, without and/or with contrast.MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. It is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor, but that a follow-up MRI is recommended. Questionable MRI findings often lead to unnecessary biopsies. Additionally, there are cases where an MRI has not detected a breast cancer (false negative). There is little evidence to support the use of MRI as a surveillance tool rather than conventional mammography.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI). The available records indicate that the patient presented with a history of right breast mass. An ultrasound of the site of a palpable lump demonstrated an irregular hypoechoic complex cystic lesion with internal vascular flow with the track that extended nearly to the skin surface consistent with an inflammatory process such as an inflamed sebaceous cyst. The patient underwent evaluation with a breast MRI. The MRI demonstrated a right breast mass, BI-RADS Category 4 suspicious for malignancy. The National Comprehensive Cancer Network (NCCN) guidelines report that breast MRI is not recommended in the diagnostic evaluation of patients who present with a palpable mass in the breast.

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 MRI, then check the rights and deadlines that apply to your plan.