Magnetic Resonance Imaging Of The Breast denials in California external review
In the California DMHC record, independent physician reviewers decided 18 published external-review cases involving Magnetic Resonance Imaging Of The Breastand overturned the plan’s denial in 33.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Magnetic Resonance Imaging Of The Breast denials
| Category | Decisions | Overturned |
|---|---|---|
| Breast Pain | 3 | 0% |
What the insurer actually argued
| 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% |
What the reviewers wrote
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
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 external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Magnetic Resonance Imaging Of The Breast, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY