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

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with right breast cancer, ER/PR positive in 1998. She underwent lumpectomy and right axillary lymph node dissection. Subsequently, she was treated with adjuvant chemotherapy followed by adjuvant radiation treatment. The patients treatment was complicated with right upper extremity lymphedema.  She previously had second primary right breast cancer (lobular invasive carcinoma).  She underwent right breast mastectomy and was found to have lobular invasive carcinoma, tumor size 1.8 cm with clear margin without lymph node involvement, ER/PR positive, HER2 negative.  The patient was treated with four cycles of adjuvant Cytoxan and Taxotere.  She has been on adjuvant endocrine therapy with Arimidex.  She has recently developed left upper extremity swelling. The provider recommended magnetic resonance imaging (MRI) of breasts. The Health Plan has denied this request indicating that the requested service is not medically necessary for the evaluation of the patients medical condition. At issue in this case is whether MRI of the breasts is medically necessary for the evaluation of this patient. The NCCN guidelines note there is no high-level data to demonstrate that the use of MRI to facilitate local therapy decision-making improves local recurrence or survival. MRI may be helpful for breast cancer evaluation before and after preoperative systemic therapy to define extent of disease, response to treatment, and potential for breast-conservation therapy. The NCCN guidelines also note, MRI may be useful in identifying otherwise clinically occult disease in patients presenting with axillary nodal metastases (cT0, cN+), with Paget disease, or with invasive lobular carcinoma poorly (or inadequately) defined on mammography, ultrasound, or physical examination. 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% based on models largely dependent on family history, such as in those with the risk associated with inherited susceptibility to breast cancer. Radhakrishna and colleagues, report that breast MRI has also proven value in evaluation of unknown primary, evaluating local extent of disease, multicentricity and bilaterally especially in dense breasts, differentiating a scar from local recurrence in women who had breast conserving surgery, evaluation of response to neoadjuvant chemotherapy and in evaluating the integrity of implants. In this case, the patient has had breast cancer diagnoses twice with a history of complex breast surgeries and adjuvant radiation therapy complicated with upper extremity lymphedema. The patient also, reportedly, has large breasts which pose a technical challenge for the standard screening of XR mammogram. Taking into consideration her clinical history and situation, she would benefit from continued use of screening a MRI instead of XR Mammogram. Therefore, MRI of the breasts is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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.