Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Fibroadenomatoid

Treatment: 77049 magnetic resonance imaging (MRI) of the breast - bilateral, A9585-JW x 49 (injection, gadobutrol - drug amount discarded/not administered to any patient), and A9585 x 51 

The insurer denied coverage for 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast.

The denial is overturned.

This patient has a history of non-Hodgkin's lymphoma, thyroid nodules, and osteopenia. The physician told the patient about an increased area of enhancement that is suspicious on the right breast that was found on magnetic resonance imaging (MRI). MRI guided breast biopsy was performed for an area of increased enhancement that was suspicious in the right breast.

The results of the patient's MRI guided biopsy demonstrated fibroadenomatoid change and pseudo angiomatous stromal hyperplasia. This is the same finding that had been identified on the prior biopsy, and the plan was to continue to follow up with annual MRI. 

It is noted in UpToDate by Slanetz, "MRI of the Breast and emerging technologies" that "appropriate use of breast MRI is established for certain indications, while others are still being investigated. Breast MRI has been used for the assessment of silicone implant integrity, diagnosis of occult primary breast cancers, determination of disease extent in newly diagnosed breast cancer patients (when indicated), documentation of response to neoadjuvant chemotherapy, diagnosis of recurrence, clarification of inconclusive clinical or mammographic findings, and screening of high-risk patients." Slanetz noted that "MRI has higher sensitivity for the detection of breast cancer in the high-risk population than mammography or US (ultrasound) and thus is recommended for screening women who are at significantly high risk (lifetime risk 20 percent or higher) for the development of breast cancer. However, there is no evidence for a reduction in mortality or improved disease-free survival from screening with MRI, despite evidence that MRI can detect smaller cancers and more node-negative malignancies in high-risk women than other imaging modalities." It is indicated for "women who received chest irradiation, such as mantle radiation for Hodgkin lymphoma, are at significantly increased risk of breast cancer."
	
MRI of the breast does have approval of regulatory bodies as a test for this diagnosis. The reviewer does believe the patient is a good candidate for the MRI in the role that it was being used as the recommendations are yearly MRI for patients at high risk.

The reviewer believes that given the recommendations this is appropriate and the best available treatment for this patient given her increased risk.

They are not increased over standard treatment risks.

Based upon the clinical information provided to me, codes 77049, A9585-JW, and A9585 x 51, magnetic resonance imaging (MRI) of the breast should be approved and that the MRI would be more beneficial than any of the standard treatments given the guidelines for patients at high risk for breast cancer.

Therefore, the denial of coverage for MRI is overturned as the indications are present for an MRI to be done.  

The carrier's denial of codes 77049, A9585-JW x 49, and A9585 x 51, magnetic resonance imaging (MRI) of the breast should be overturned.