Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of Breast Cancer
Treatment: Magnetic Resonance Imaging (MRI) of breasts (procedure code 77049)
The insurer denied coverage for MRI of breasts (procedure code 77049).
The denial is upheld.

According to the clinical documentation provided for review, the patient is a female with history of cancer of the right breast. It was reported the patient felt a small lump. A mammogram and ultrasound were completed showing a 6-millimeter (mm) tumor. The treating provider performed a breast magnetic resonance imaging (MRI) scan for evaluation. 

The use of breast MRI in the preoperative evaluation of a newly diagnosed breast cancer has increased significantly over the last two decades. However, there are no data from prospective randomized trials that demonstrate improved outcomes from the addition of breast MRI to the diagnostic evaluation of newly diagnosed breast cancer.  MRI may be used for staging evaluation to define extent of cancer or presence of multifocal or multicentric cancer in the ipsilateral breast, or as screening of the contralateral breast cancer at time of initial diagnosis (category 2B). There are no high-level data to demonstrate that the use of MRI to facilitate local therapy decision making improves local recurrence or survival. 

False-positive findings on breast MRI are common. Surgical decisions should not be based solely on the MRI findings. Additional tissue sampling of areas of concern identified by breast MRI is recommended. 

The utility of MRI in follow-up screening of patients with prior breast cancer is undefined. It should generally be considered only in those whose lifetime risk of a second primary breast cancer is >20% (percent) based on models largely dependent on family history, such as in those with the risk associated with inherited susceptibility to breast cancer. 

Based on the documentation reviewed, none of the National Comprehensive Cancer Network (NCCN) Guidelines for Breast Cancer (2022) criteria appear to be present in this case. 

"Early detection decreases breast cancer mortality. The American College of Radiology (ACR) recommends annual mammographic screening beginning at age 40 for women of average risk. Higher-risk women should start mammographic screening earlier and may benefit from supplemental screening modalities. For women with genetics-based increased risk (and their untested first-degree relatives), with a calculated lifetime risk of 20% or more or a history of chest or mantle radiation therapy at a young age, supplemental screening with contrast-enhanced breast MRI is recommended. Breast MRI is also recommended for women with personal histories of breast cancer and dense tissue, or those diagnosed by mid-age. Others with histories of breast cancer and those with atypia at biopsy should consider additional surveillance with MRI, especially if other risk factors are present. Ultrasound can be considered for those who qualify for but cannot undergo MRI. All women, especially black women and those of Ashkenazi Jewish descent, should be evaluated for breast cancer risk at an early age so that those at higher risk can be identified and can benefit from supplemental screening." (Monticciolo, et al., 2018) 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for magnetic resonance imaging (MRI) of breasts (procedure code 77049) is upheld. Medical necessity is not substantiated.