MRI Of The Breast denials in California external review

What the reviewers wrote

Where the denial was overturned

A 56-year-old female enrollee has requested a magnetic resonance imaging (MRI) scan of the chest/breasts and a positron emission tomography (PET) scan for evaluation of her status post ductal carcinoma in situ (DCIS) surgery. Findings: Two physician reviewers found that a follow-up MRI showed an additional mass in the upper inner quadrant 1.5 cm in diameter which also proved to be malignant. A PET scan performed on the date in question showed no evidence of metastatic disease. A repeat MRI of the breasts/chest and a PET scan were requested for follow-up. Additional information has been submitted which indicates that when the patient presented to her provider on the date in question, there were concerns regarding a hardened area under her scar, subsequent to radiation treatment.

A 46-year-old female enrollee has requested a MRI of the breast for evaluation of her segmental mastectomy. Findings: Three physician reviewers found that this patient has a history of invasive ductal cancer of the left breast which is triple negative. There is a known propensity for this type of tumor to be multifocal in the involved breast and sometimes occurs in the contralateral breast. The providers caring for this patient have observed several foci of abnormal enhancement in the treated left breast outside of the surgical resection site on an outside MRI. Mammographic and sonographic evaluation of these areas has been negative. Since the abnormalities were only visible on MRI it is reasonable to image the breast to evaluate for any progression using the only modality on which they have been evident.

Where the denial was upheld

A 56-year-old female enrollee requested authorization and coverage for a magnetic resonance imaging (MRI) scan of the chest/breasts and a positron emission tomography (PET) scan. Findings: Two physician reviewers found that the patient had a positive biopsy for ductal carcinoma in situ (DCIS) and underwent an MRI of the breasts. In the right breast, the patient was noted to be status post lumpectomy and radiation changes with a new stereotactic staple within the 3:00 position. For this new area, an excisional biopsy was recommended and performed and the specimen was consistent with high grade DCIS. In addition, a PET scan was negative, with no noted pathologic hypermetabolic activity. A summary of the lumpectomy report states the size of lesion was 1.5 cm and high grade DCIS was identified, solid and cribiform type. No lymph nodes were noted to be present.

The patient is a 42-year-old female who had bilateral mammograms and breast sonograms in April 2005. Bilateral simple cysts were present with probable benign small complex cysts seen in both breasts. A six-month follow-up exam was suggested. MRI of the breasts was performed in June 2005, which showed two small masses on the right and one on the left and ultrasound-guided biopsies were suggested. In July 2005 biopsies of nodules in the right breast at 9 o’clock and 12 o’clock were performed, which showed adenosis and focal apocrine metaplasia. Follow-up MRI and ultrasound of both breasts was recommended in six months. A bilateral breast ultrasound in October 2005 showed no suspicious nodules with the previous complex cysts either stable or resolved.

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