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

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 presently requesting MRI of the chest/breasts and a PET scan for post DCIS follow-up. She also states she has a bump in the medial right breast, and questions whether it is scar or recurrent tumor. The Health Plan indicates the requested diagnostic scans are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The indications for breast MRI have been clearly defined by the American Cancer Society and specific guidelines have been established. These include a patient with a defined high risk of developing breast cancer, someone newly diagnosed with breast cancer to evaluate the extent of disease, assessment of disease after treatment, as well as several other specific indications. In a recent article, Jessica and Leung suggested that MRI is of little added benefit when both mammography and ultrasound are negative, and should be reserved for high risk patients. This is especially true in light of the high sensitivity and low specificity of MRI, which is likely to result in an excess of negative and false positive biopsies (Jessica & Leung). MRI has not been demonstrated to have a role in the current literature for patients without mammographic or ultrasound findings and no documented high risk factors. This patient does not fit the high risk category as defined by the American Cancer Society and the American College of Radiology. There is no documentation of recent mammogram or ultrasound identifying an area of clinical concern. MRI is not an appropriate first step modality. In this case, MRI of the breasts/chest is not likely to be clinically useful and is not indicated for this patient.With regard to the requested PET scan, this modality is generally indicated for restaging after the completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence or to determine the extent of a known recurrence. This patient does not meet these criteria. The use of PET would also be considered reasonable and necessary to potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient (Isasi, et al.). In this case, there is no documented recurrence; therefore, PET scanning is not indicated.