Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Family history of cancer.
Breast MRI Study (CPT 77049).
The insurer denied the Breast MRI Study (CPT 77049).
The denial is upheld. 

The patient is a female with no personal history of breast cancer. She has a family history that includes a maternal grandmother who had ovarian cancer diagnosed. A maternal aunt had breast cancer. Two maternal cousins (daughters of the affected aunt) had breast cancer. A third maternal cousin had breast cancer.

The patient's lifetime risk of breast cancer calculated was 19.9%, based on the Tyrer-Cusick model.

The request is for coverage of screening breast MRI (magnetic resonance image), based on an increased genetic risk of breast cancer.

No, the breast MRI is not likely to be more beneficial.

The patient has a family history of breast and ovarian cancer. Her lifetime risk of breast cancer is 19.9% based on the Tyrer-Cusick model. On the basis of a 19.9% lifetime risk of breast cancer, a screening bilateral breast MRI (magnetic resonance image) was performed.

The American Cancer Society published recommendations for screening breast MRIs (magnetic resonance images) (Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, Morris E, Pisano E, Schnall M, Sener S, Smith RA, Warner E, Yaffe M, Andrews KS, Russell CA; American Cancer Society Breast Cancer Advisory Group. "American Cancer Society guidelines for breast screening with MRI (magnetic resonance image) as an adjunct to mammography." CA Cancer J Clin. (2):75-8). The ACS (American Cancer Society) guidelines also recommend screening breast MRIs (magnetic resonance images) only in women with a greater than or equal to 20% lifetime risk of developing breast cancer.

The ACS (American Cancer Society) recommendations specifically discuss the use of genetic models for predicting risk of development of breast cancer:

The ACS (American Cancer Society) supports the use of the BRCAPro (BReast CAncer gene), Claus, and Tyrer-Cuzick models.

This patient's risk was calculated with the Tyrer-Cuzick model (Tyrer J, Duffy SW, Cuzick J.) which is among the accepted models.

The current NCCN (National Comprehensive Cancer Network) Guidelines also support the use of the Tyrer-Cuzick model for calculation of lifetime risk of breast cancer for the purpose of determining the need for screening breast MRIs (magnetic resonance images) (NCCN [National Comprehensive Cancer Network] Guidelines Version 1.  Breast Cancer Screening and Diagnosis, page BSCR-1). The NCCN (National Comprehensive Cancer Network) Guidelines support screening breast MRIs (magnetic resonance images) for a greater than or equal to 20% lifetime risk of breast cancer.

The issue with the breast MRI (magnetic resonance image) in this case is that the patient's lifetime risk of breast cancer is less than 20%. This reviewer recognizes that 19.9% is very close to 20%, but it is less than 20%. If the cutoff recommendations are not strictly followed, it would leave no rationale threshold to interpret a cutoff. "Rounding up" is not supported.

As the benefit of screening breast MRIs (magnetic resonance images) in women with less than a 20% lifetime risk of breast cancer is unproven, this testing would not be medically appropriate.