Breast Magnetic Resonance Imaging denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with right breast cancer, ER/PR positive in 1998. She underwent lumpectomy and right axillary lymph node dissection. Subsequently, she was treated with adjuvant chemotherapy followed by adjuvant radiation treatment. The patient’s treatment was complicated with right upper extremity lymphedema. She previously had second primary right breast cancer (lobular invasive carcinoma). She underwent right breast mastectomy and was found to have lobular invasive carcinoma, tumor size 1.8 cm with clear margin without lymph node involvement, ER/PR positive, HER2 negative. The patient was treated with four cycles of adjuvant Cytoxan and Taxotere. She has been on adjuvant endocrine therapy with Arimidex. She has recently developed left upper extremity swelling. The provider recommended magnetic resonance imaging (MRI) of breasts.

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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast magnetic resonance imaging for evaluation of the enrollee who presented for an annual breast examination. Findings: The physician reviewer found that while breast MRI has an important role in both screening and diagnostic settings, the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. In the last several years, the American Cancer Society (ACS) and the American College of Radiology (ACR) have established guidelines for the appropriate use of breast MRI. As per the ACS/ACR guidelines, those screening indications include screening for the high risk patient, screening the contralateral breast in a patient with a recently diagnosed breast malignancy, and screening in patients with breast augmentation.

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.

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 Breast Magnetic Resonance Imaging, then check the rights and deadlines that apply to your plan.