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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for a breast MRI. The enrollee has invasive ductal carcinoma of the right breast. A palpable mass was found in the upper portion of the right breast. A magnetic resonance imaging (MRI) scan of the bilateral breast showed an 18mm mass in the right breast at 12 oclock, compatible with known malignancy. She will undergo right lumpectomy and sentinel node biopsy, pending results of genetic testing. The enrollee is newly diagnosed with breast cancer. She has dense tissue. Her physician recommended the MRI to determine if a lumpectomy or a mastectomy was needed. The physician maintains this is the standard of care according to professional guidelines for breast cancer treatment in an individual this age. The medical literature indicates that an MRI may be used for restaging, for evaluation, to define the extent of cancer, to determine the presence of multifocal or multicentric cancer in the ipsilateral breast, or for screening of the contralateral breast cancer at the time of diagnosis.  Surgical decisions were not solely based on the MRI findings. The enrollee underwent a biopsy subsequent to the MRI. The enrollees surgeon recommended this study to assess the extent of the disease and to search for other sites of possible malignancy in the same breast and bilaterally. The indication for breast MRI in this enrollee is newly diagnosed breast cancer, dense breasts on mammography, a family history of breast cancer in a sister, diagnosed with breast cancer at age thirty; and the need to rule out multifocality; if present, this would eliminate the possibility of treatment with lumpectomy. Professional societies recommend against MRI screening for women with a lifetime risk of breast cancer of less than 15%. Those at higher risk should utilize MRI in addition to a screening mammogram. Literature notes MRI of the breast has the highest sensitivity for breast cancer detection among current clinical imaging modalities. It is indispensable for breast imaging practice. While the basis of breast MRI consists of T1-weighted contrast-enhanced imaging, other parameters may be used to improve lesion characterization, providing better discrimination between benign and malignant breast lesions. Indications for breast MRI are expanding. In preoperative staging, multiple studies confirm the superiority of MRI to other imaging modalities for tumor size estimation and detection of additional tumor foci in the ipsilateral and contralateral breast. MRI is also used to document response to neoadjuvant chemotherapy. Professional guidelines recommend an annual breast MRI for those who have a lifetime breast cancer risk of greater than twenty percent; as defined by models largely dependent upon family history. Her risk was not clearly defined in the documentation, but since she is young with a family history, it was more beneficial to obtain an MRI prior to surgery; especially since breast tissue can be dense and lesions could be missed on a simple mammogram. Breast MRI for this specific enrollee would be more beneficial than standard ultrasound or mammogram. Final Result: Three of the three reviewers determined that the requested services were  likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in general surgery and are actively practicing.  All three reviewers are experts 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.