Home / Treatments / Magnetic Resonance Imaging Of The Breast
Magnetic Resonance Imaging Of The Breast denials: what the review data shows
Independent reviewers have decided 18 published cases where an insurer denied Magnetic Resonance Imaging Of The Breast — and they overturned the insurer 33.3% of the time. A denial for Magnetic Resonance Imaging Of The Breast is a starting position, not a final answer.
Published decisions
18
2001–2026
Overturned
33.3%
6 denials reversed
Conditions behind magnetic resonance imaging of the breast denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Breast Pain | 3 | 0% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 13 | 38.5% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 5 | 20% |
Typical time to a decision
14 days
Most land between 7 and 18 days
Handled as urgent
27.8%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) (CPT 77046) of the right breast. Findings: The physician reviewer found that Evaluation of the chest area after bilateral mastectomy and reconstruction is challenging. Mammogram is not recommended in the absence of breast tissue. Ultrasound has not been demonstrated to be as comprehensive or useful as MRI in this clinical setting. Post-mastectomy MRI in the setting of reconstruction has been shown to be the most effective modality for the detection of recurrent cancer, as well as other issues. In this patient’s case, the MRI was helpful to assist the provider in deciding whether a biopsy should be done, and if so, the location to biopsy.
A 64-year-old female enrollee requested magnetic resonance imaging (MRI) of the breasts for medical evaluation and treatment. Findings: Three physician reviewers found that the patient underwent removal of bilateral breast implants and replacement of the implants due to right implant rupture. According to the provider, a breast ultrasound demonstrated rupture of right breast implant and free silicone. Magnetic resonance imaging (MRI) of the breasts revealed evidence of right breast intracapsular rupture and free extracapsular silicone within the left lateral breast and right axillary lymph nodes. Subsequently, the patient underwent surgery to remove the implants and some of the silicone. Bilateral diagnostic mammogram and targeted breast ultrasound showed right axillary silicone containing lymph nodes.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left breast. The American College of Radiology (ACR) has established appropriateness criteria to help guide providers select the most efficacious imaging procedures for individual patients. Per the ACR recommendations, the first step in evaluating a patient is to obtain a mammogram. Even in patients with breast implants, a mammogram and a sonogram are supported for routine use. However, breast MRI is considered usually not appropriate for use in routine screening. This patient’s records do not include documentation that the patient has undergone initial evaluation with a routine mammogram. There are various classic appearances on a routine mammogram that are diagnostic for implant rupture.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT) of the breasts and/or magnetic resonance imaging (MRI) of the breasts. Per Sharma and colleagues, patients with Breast Implant-associated Anaplastic Large Cell Lymphoma (BIA-ALCL) have been found to present with “rapid and dramatic (breast) swelling as a result of peri-prosthesis effusion (85%) or as a palpable mass (15%) adjacent to the prosthesis in the affected breast.” Rupani and colleagues recommend focused ultrasound as a first-line imaging modality to evaluate for possible peri-implant effusion. Sharma and colleagues also reported that focused ultrasound is appropriate for assessing breast masses associated with BIA-ALCL as well as skin edema.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Magnetic Resonance Imaging Of The Breastwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.