Breast MRI denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for a breast MRI. The enrollee has invasive ductal carcinoma of the right breast. A palpable mass was found in the upper portion of the right breast. A magnetic resonance imaging (MRI) scan of the bilateral breast showed an 18mm mass in the right breast at 12 o’clock, compatible with known malignancy. She will undergo right lumpectomy and sentinel node biopsy, pending results of genetic testing. The enrollee is newly diagnosed with breast cancer. She has dense tissue. Her physician recommended the MRI to determine if a lumpectomy or a mastectomy was needed. The physician maintains this is the standard of care according to professional guidelines for breast cancer treatment in an individual this age.

A 41-year-old female has requested a breast MRI for evaluation of her medical condition. Findings: Two physician reviewers found that the patient has a positive family history of breast cancer and of Ashkenazi Jewish descent, placing her at significant increased risk of breast cancer. Genetic testing revealed she is BRCA-1 negative. Her mammograms demonstrate extremely dense breast tissue which markedly limits the utility of mammography in her case. The patient had a MRI of the breasts where a suspicious area of enhancement was seen in the left breast. Targeted ultrasound was equivocal at best. She had a follow-up MRI scan which showed a persistent area of enhancement in the left breast. MRI guided biopsy was suggested. She was scheduled for the planned biopsy but the MRI failed to reveal the abnormal area of contrast enhancement.

Where the denial was upheld

A 42-year-old female enrollee has requested coverage for a MRI of the breasts for evaluation of her medical condition. Findings: Two physician reviewers found that this patient has a positive family history of breast cancer in her grandmother who was diagnosed at the age of 55. The patient underwent aspiration of a left breast cyst two years ago. Clinically, the patient had areas of palpable thickening within both breasts. A diagnostic mammogram, performed a year later showed dense breast tissue with no evidence of malignancy. A bilateral breast ultrasound performed in conjunction with the mammogram showed a benign finding within the right breast and no suspicious findings. A follow-up mammogram was recommended in one year. The patient’s provider has requested a bilateral breast MRI which was denied by the Health Plan.

A 53-year-old female has requested coverage for a past bilateral breast MRI for evaluation of her breast pain. Findings: The physician reviewer found that this patient presented with right breast pain with a history of breast implants, and no breast abnormalities were noted on physical examination. She was referred for a breast MRI as a screening study for breast cancer and also as a diagnostic study to evaluate the patient’s right breast pain. Per the submitted records, the patient did not undergo a recent mammography or breast ultrasound prior to the MRI study. Patients who have breast implants can safely undergo mammography, and mammography is the gold standard for screening of breast cancer and to evaluate breast abnormalities and/or breast symptoms. The indications for a screening breast MRI are well-established in the peer-reviewed medical literature.

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