Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1:  The patient is a 59-year-old female who was diagnosed with infiltrating lobular carcinoma of the right breast in June 2006. Her surgeon has requested bilateral MRI of the breasts to determine the extent of the disease within the right breast and to evaluate for synchronous tumor within the left breast. The surgeon has submitted a request for authorization of bilateral breast MRIs prior to surgery. The Health Plan denied the request based upon a determination that the diagnostic procedure is experimental/ investigation in this clinical setting.There are several established indications for MRI screening of the breast with malignant disease which include preoperative evaluation of the extent of the cancer, postoperative assessment of residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. The high risk patients are those with a personal history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene, biopsy proven atypia, lobular carcinoma in situ, radial scar, and prior mantle radiation. MRI has been requested for this patient to determine of the extent of disease and the extent of lobular cancer. The prevalence of contralateral synchronous lobular cancer has been reported to be between 10% and 36%. The infiltrative nature of lobular cancer can make mammographic detection difficult; therefore MRI evaluation of the breasts is indicated. Based on these facts, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2:  The patient is a 59-year-old female who first noticed nipple retraction three months prior to the current diagnosis of right breast cancer. She underwent bilateral mammograms in June 2006 and the possibility of architectural distortion was noted on the magnification views. An ultrasound was performed on the same day revealing an 18mm x 12mm hypoechoic mass in the upper outer quadrant of the right breast, 5cm from the nipple. This lesion was subsequently biopsied revealing grade II infiltrating carcinoma, likely infiltrating lobular carcinoma. The patient was seen and evaluated by a surgical oncologist who requested bilateral breast MRIs to further evaluate the extent of the patients disease. The request was denied by the Health Plan citing the experimental/investigation nature of the diagnostic procedure in this clinical context.Infiltrating lobular carcinoma (ILC) of the breast has a higher incidence of multifocality and contralateral disease than infiltrating ductal carcinoma. Although ILC is much less common that infiltrating ductal carcinoma (IDC), there is sufficient experience to allow documentation of its distinct characteristics. ILC is poorly visualized on mammogram and ultrasound; the full extent of the tumor is often underestimated by these radiologic studies. MRI has been found to be more accurate in the estimation of the tumor size. This point is critical in the treatment planning as an accurate estimate of tumor size is essential before a recommendation can be made for lumpectomy versus mastectomy. The patient has a tumor 5cm from the nipple, but presented with signs of nipple retraction. This may suggest tumor involvement much closer to the nipple than has been identified by mammogram or ultrasound. Thus, the findings of the MRI may change the local treatment considerably. Additionally, the lobular histology of ILC is a marker for bilateral disease and there is a significantly higher rate of multicentricity as compared to IDC. MRI has been found to be more sensitive than mammography for detecting bilateral disease in the setting of a lobular cancer. The added risk factors associated with ILC coupled with the generally poor radiologic evaluation of ILC by mammogram makes MRI evaluation prior to surgical intervention essential for this patient.Based upon the information set forth above, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 59-year-old female who noted changes in the right breast which lead to x-ray mammography and ultrasound evaluation.  The 18mm by 12mm mass identified in the right breast was biopsied and the pathology report showed grade II infiltrating lobular carcinoma. The enrollee was referred to surgical oncology in July 2006. The surgeon noted that although the current evidence indicated the patient had stage I disease, there is a high probability of ipsilateral or contralateral spread with this type of carcinoma. The surgeon recommended screening of both breasts thoroughly before planning definitive surgical intervention.  A request for bilateral breast MRIs was submitted to the Health Plan. Authorization was denied on the premise that preoperative breast MRI is an experimental/investigational procedure.It is well known that infiltrating lobular carcinoma carries with it a high probability of synchronous lesions, both ipsilateral and contralateral. MRI is the examination of choice in this setting because of its high sensitivity. MRI, as ordered by the treating oncologist, represents the current state of the art and best practice in surgical oncology and radiology. The procedure is well established and is not considered investigational. Therefore, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.