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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast magnetic resonance imaging for evaluation of the enrollee who presented for an annual breast examination. Findings:  The physician reviewer found that while breast MRI has an important role in both screening and diagnostic settings, the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. In the last several years, the American Cancer Society (ACS) and the American College of Radiology (ACR) have established guidelines for the appropriate use of breast MRI. As per the ACS/ACR guidelines, those screening indications include screening for the high risk patient, screening the contralateral breast in a patient with a recently diagnosed breast malignancy, and screening in patients with breast augmentation. The accepted indications for diagnostic MRI of the breast is to evaluate extent of disease in patients with invasive, carcinoma or ductal carcinoma in situ (DCIS), in assessing invasion deep to the fascia, post lumpectomy with positive margins, or following patients with neoadjuvant chemotherapy. Overall, MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. This patient has consistently had stable mammograms, which is probably the best indication that she does not have tumor. The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  In this patients case, there is no evidence in the documentation provided to support the use of MRI as a surveillance tool rather than conventional mammography.  As noted in one study, It is thought that there is inconclusive evidence regarding MRI screening of women with a personal history of breast cancer, lobular carcinoma in situ, atypical lobular hyperplasia, atypical ductal carcinoma, dense breast tissue, and lifetime risk levels of 15% to 20%. While the patient may have concerns regarding damage to her implants from the compression used during a screening mammogram, most researchers feel that the implants are sufficiently malleable and that ruptures do not occur from compression. As such, mammography should not be avoided in patients, even those with implants. This patients past mammograms have demonstrated that her native breast tissue is fatty, and mammography is especially accurate in patients with fatty breasts. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation 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.