Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for bilateral magnetic resonance imaging of breast, without and/or with contrast.MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. It is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor, but that a follow-up MRI is recommended.  Questionable MRI findings often lead to unnecessary biopsies. Additionally, there are cases where an MRI has not detected a breast cancer (false negative). There is little evidence to support the use of MRI as a surveillance tool rather than conventional mammography. Medical literature noted, Studies identifying more accurate and reproducible methods of identifying women with dense breasts are needed. There were no published studies of important longer-term clinical outcomes of supplemental screening. In general, supplemental screening of women with dense breasts will lead to the identification of more breast cancers (mostly invasive) but may be associated with higher recall rates and additional biopsies. Whether cancers identified by supplemental screening have better outcomes and how many of them represent cancers that would not otherwise become clinically apparent (overdiagnosis) cannot be determined from the studies published to date. Rigorous comparative studies of supplemental screening for women with dense breasts including clinical outcomes beyond breast cancer diagnosis are needed for all modalities. Researchers state that indications for breast MRI include, determination of the stage and extent of disease in a patient with newly diagnosed breast cancer, evaluation of a patient with an unknown primary tumor, evaluation of a patient with positive surgical margins after breast conservation surgery, monitoring of a patient undergoing neoadjuvant chemotherapy, evaluation of breast implant integrity, screening for breast cancer in a woman at very high risk for the disease, and use as a problem-solving tool for a woman with equivocal mammographic findings.In this case, the patient has already had a tomosynthesis examination. Further, the most important indicator that she does not have cancer is comparison to her older mammograms and observation of benign lesions. Moreover, the use of MRI in the patients case is not indicated based on the medical literature. Therefore, bilateral magnetic resonance imaging of breast, without and/or with contrast is not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.