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Insurance company will not cover my MRI



  • emanresu
    emanresu Member Posts: 13
    edited January 2009

    cp418 wrote: Some how we need to organize a petition do go directly to the governing powers. 

    I agree!

    And all of these groups that are helping, the ones with the pink ribbons. They have clout send them to Washington to go to bat for us. We should ask the pink ribbon groups to make it a priority that breast cancer patients have a right to an MRI.

    Mary Grace.

  • AccidentalTourist
    AccidentalTourist Member Posts: 72
    edited January 2009

    Thank you and good luck everyone in our fight for screening (as if we are asking for some unnecessary luxury).

  • otter
    otter Member Posts: 757
    edited January 2009

    MAMHOP, doesn't your doc have to get pre-approval from BCBS for a breast MRI?

    Mine did, even though the pre-surgery MRI was justified by my doc because of my dense breast tissue and a biopsy-confirmed dx of IDC that was never seen on mammograms (including digital mammos).  BCBS fussed a bit, but the cancer center told me not to worry--they would get it approved.  Note that it wasn't a screening MRI, though.

    I was thinking if they had to get pre-approval, you'd know ahead of time whether BCBS was going to cover it.  OTOH, the fine print in my policy notes that pre-approval doesn't mean they're actually going to pay for it in the end.  It just means the procedure looks like it is probably medically necessary at the time of the request.


    I think what would really help is if we (or someone) can get the "medical necessity" threshold for MRI's lowered.  We shouldn't have to show we have dense breast tissue + a mom and 5 siblings dying of BC + BRCA1 positivity + biopsy-proven LCIS before "the powers" decide routine screening MRI's would be of benefit.  (Okay, that was exaggerated, but not by much.)

    This is off-topic, but the same thing happened with insurance coverage for Neulasta and Neupogen to boost bone marrow activity during chemo.  At first, and to this day with some insurance companies, the patient must develop febrile neutropenia and/or end up in the hospital before they'll pay for Neulasta shots for subsequent rounds of chemo.  Then they started paying for Neulasta or Neopogen up-front (first round of chemo) for women on chemo regimens that were highly likely to cause febrile neutropenia.  Then they agreed to pay for Neulasta or Neopogen if the chemo was kind of likely to cause febrile neutropenia ... etc.  The threshold kept dropping so it was easier to get approval for up-front Neulasta.

    Maybe that will happen with breast MRI's.  Right now, the criteria are very stringent with most companies.  I wonder what might get them to reconsider?  Someone is going to have to show that the insurance companies will save money in the end by paying for screening MRI's in more women. 


  • PSK07
    PSK07 Member Posts: 91
    edited January 2009

    While calling attention to this in Washington may be a good idea, I urge anyone who has unresolved issues with their insurance company to consider contacting their State Insurance Commissioner.  Most insurance policy coverage requirements are set at the state, not national, level. If you are covered by an employer, and that employer is self-insured, it becomes more difficult, but not impossible to get things turned around.

    In Washington State we have a very consumer-oriented insurance commission. We have also pioneered requiring some medical treatments be provided by insurors offering group coverage in the state.  Things such as mental health parity, alternative/complementary medicine, etc.

    In many cases, if it looks like they company will continue to deny, deny, deny, one letter to the Ins Commissioner and cc'd to the insurance company (or vice versa) will do the trick. 

    My mother initially had her treatment for BC denied because the insurance co. decided it was a pre-existing condition (she changed companies about 3 months prior to her dx). It took her surgeon, PCP, and onc, along with a well-timed letter to the State to get the decision turned around. 

  • otter
    otter Member Posts: 757
    edited January 2009

    [edited to add: this page is way too wide on my screen, because there's a link in a post above this post that doesn't have a line break in it] 

    cp418, thanks for the link.  That's an editorial/commentary about an original research paper:  Houssami H., et al.:  "Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging:  systematic review and meta-analysis in detection of multifocal and multicentric cancer."  Journal of Clinical Oncology 2008; 26:3248-3258.  Here's a link to the abstract of the original article in PubMed:

    Here is an excerpt--basically, the conclusion--from the editorial/commentary posted by cp418.  It highlights the problem we're having, trying to convince our doctors or insurance companies to let us have breast MRI's:

    "With multiple studies characterizing the accuracy of MRI and a thoughtful meta-analysis by Houssami, we should focus on addressing the larger question of how MRI impacts patient outcome in terms of local recurrence rates, contralateral breast cancer rates, and ultimately, survival. This focus is especially important since Houssami's meta-analysis contributes to other published studies that describe an association between the use of MRI and more extensive surgery. In breast cancer care, we strive to make evidence-based decisions. With multiple studies demonstrating that we can control conventionally occult disease with resection to negative margins and whole-breast irradiation, and other studies showing significant reductions in local recurrence with chemotherapy and endocrine therapy, it is difficult to determine the best treatment for disease detected only by MRI. As a result, the meta-analysis by Houssami and colleagues on the accuracy of surgical impact of MRI is certainly of practical, daily importance. However, the FP [false-positive] rate of MRI is often associated with more extensive surgery and highlights the need for a large, prospective, multi-institutional study aimed at determining if the additional workup and more aggressive surgery provide our patients with any demonstrable outcome benefit. With the current low rates of local recurrence, however, such a study would require many patients for adequate power and may be difficult to justify both economically and scientifically. In the meantime, Houssami's metaanalysis can be used to guide discussions with our patients regarding the effects MRI may have on their care." 

    It's important to point out that the Houssami study being analyzed in the editorial/commentary dealt only with the use of MRI for staging BC that had already been diagnosed in one breast.  (In other words, Houssami's meta-analysis looked at studies in which MRI was used after the BC diagnosis, but prior to surgery, to see if there were other tumors in either breast.)  It was not a study of the use of MRI for screening purposes, which is what this thread is all about. 


  • cp418
    cp418 Member Posts: 359
    edited January 2009

    Otter - Thanks very much for the clarification.  Probably posting that link only caused confusion to the origin thread.

  • OneBadBoob
    OneBadBoob Member Posts: 63
    edited January 2009

    Well guys, I sent an E-Mail to CareCore and Healthnet, demanding to know the particulars about Dr.J.Saxon, who denied my MRI pre-cert, demanded a copy of his CV, demanded to know whether he was licensed to practice medicine in the State of New York, demanded to know his board certifiations if any,  and informing them that I was filing a complaint with the NYS Board of Education against him for (1) practicing medicine in NYS without a license (2) prescribing medical treatment for a patient without having first examined the patient.

     Well, knock me over with a feather.  My pre-cert request for a bi-lateral MRI was appoved this morning.

    Keep fighting ladies!!  These dirt bag insurance companies are counting on us letting it go!

  • Deirdre1
    Deirdre1 Member Posts: 22
    edited January 2009

    Good for you!  And yes they do count on us to leave it at "no". 

  • Deb-from-Ohio
    Deb-from-Ohio Member Posts: 102
    edited January 2009

    Strange I was on the phone for an hour this morning about this same thing...the insurance company said they sent out a letter asking for the medical neccesity of my MRI.....only thing is the dumbbutts sent it to a billing company.....I called them back and told them to send it to my maybe if you have your oncologist send a letter to the insurance company stating the medical neccesity of it, they might just pay it......


  • otter
    otter Member Posts: 757
    edited January 2009

    WAY TO GO Jane!  What a terrific argument you presented to them.


  • dlb823
    dlb823 Member Posts: 2,701
    edited January 2009

    Great lesson, Jane.  Thank you!  It seems like there should be a way to get some of the great information in this thread anchored somewhere here where women who need it can find it every time. 

  • otter
    otter Member Posts: 757
    edited January 2009

    That was such a great story that Jane gave us.  I hesitate to even report this, but I must.  I'm afraid that if I had challenged the denial of a claim or a precertification with those arguments, my insurance company would not have flinched.  They would have pointed out that they were not refusing to allow the diagnostic procedure or treatment that my doctor had recommended.  They were simply refusing to pay for it.

    My insurance policy states, over and over again, that decisions about my medical care must be made by my doctor, and will not be made by my insurance company.  My insurance company says they will not second-guess or countermand my doctor's recommendations.  However, they will decide whether or not they are going to pay for the procedures my doctor wants to use.

    We all know that, with the cost of medical care today, there really is no practical difference between denying the procedure and denying insurance coverage for it.


  • OneBadBoob
    OneBadBoob Member Posts: 63
    edited January 2009

    Okay guys, this should definitely be "pinned" to the top on one of our boards.  Help getting thorugh treatment, maybe?  We should all write to the moderators about this.

    I had this same problem getting my post/chemo pet/ct scan appoved.  Wrote a really long post, too tired to look it up right now--but, those dirt bags denied it becaue it was scheduled on the same day.  Excuse me?  These tests are run in the same machine (no need to move you--just change the IV solutions)--So, I went off the wall and asked what it would take to get the approval on the same day--they said medical necessity--I called my onc and told him if I had to go two separate days, two separate procedures, I may have to check myself into the "nut house."  So, he wrote them that I was "emotionally incapable" of going into this machine twice, and they approved the procedure to be done on one day.


    I have started a lawsuit against Healthnet for Intentional Infliction of Emotional Distress over all of their denials.  I know I have posted this before, and repetition is boring, but for new folks, we must stand up and fight to get the benefits we have been paying for each and every month we pay our health insurance premiums.

    Taking a deep breath and calming down before rambling any further. . .

  • kmccraw423
    kmccraw423 Member Posts: 885
    edited January 2009

    This is outrageous.  My insurance company did pay for a MRI when both mammagram and ultrasound showed nothing.  The radiologist said it was a cyst and everything was normal.  Thank God my surgeon wasn't buying it and ordered a MRI.  The left breast lit up like a Christmas tree.  The MRI did not show anything on the right but I opted for a bilateral mastectomy.  The pathology report showed early DCIS in the right breast.

    I would have thought the federal laws passed on women's health would put an end to this nonsense and you are right - insurance companies practicing medicine without a license.  I am going to look up the federal laws to see exactly what rights we have.  How can we possibly get an early diagnosis when we can't get the tests done?

  • RadiologyBiller
    RadiologyBiller Member Posts: 2
    edited January 2009

    Hello, Ladies...

    First, I would like to extend my condolences to each of you who have been diagnosed with breast cancer or who may be facing that diagnosis.  My thoughts and prayers are with you.

    As you may be able to tell from my screen name, I work for a radiology billing company.  Our group physicians are the owners of the corporation and have a joint venture with an breast MRI center.  Needless to say, my office provides the billing service for the breast MRI facility.  Every single day we face denials from insurance companies for the MOST ABSURD AND RIDICULOUS REASONS.  And every single day we work diligently to appeal the denial decisions on behalf of our patients.  

    Believe it or not, there are actually some insurance carriers out there who do pay without a fuss. Unfortunately, some of the larger carriers - BCBS in particular - seem to cook up any excuse possible to not pay for the services.  Obviously this is not news to you or this topic wouldn't even be posted.  =)

    Now, here's the kicker with BCBS...THEY WILL NOT PRE-CERTIFY OR PRE-AUTHORIZE THESE SERVICES (or any, for that matter).  Basically, you just take your chances - have the service and then cross your fingers and pray like crazy.  If you do have BCBS - any plan within the Blue Cross group - I would strongly recommend you start by taking the following actions before you have your MRI:

    1.     Get copies of all of your relevant medical records (anything indicating a previous breast cancer history, record of family history, most recent mammogram(s) and ultrasound(s), and biopsy [if applicable]) and a statement from your physician setting forth his/her reasons for deeming the MRI a medical necessity.

    2.     More than likely the breast MRI facility will be aware of the denial issue.  But, to err on the side of caution, tell them that you are aware there may be a problem and make sure the breast MRI facility - or billing office - has copies of your relevant medical records and physician statement.  Ask them to file a PAPER CLAIM (do not send the claim electronically) and attach copies of the medical records you provide, as well as the MRI report itself.  

    3.     Ask them to please point out in a cover letter the areas in the attached medical records that show your risk factors (previous history, mammogram results, ultrasound results, biopsy results, physician statement).  Ask them to be specific - "...on page 2 of Mrs. Brown's ultrasound report dated March 1, 2008, the impression is that of (whatever it may be)..." "...on page 2 of Mrs. Brown's mammogram report dated February 25, 2008 the impression is (whatever it may be)..."  and so on and so forth.  I know this may seem to be a little much to ask, but hey...if it works, it IS their bill that will be getting paid.  

    4.  Ask them to provide you with a copy of what is submitted to the carrier.  (This way you know it's done like you asked...and you have your own copy in the event you need to file your own personal appeal.)

    I am suggesting these things because this is the new approach my office is taking with our ladies who are in the same situation.  And guess where the suggestion came from...A letter sent to a patient from BCBS in which they indicated that while they don't do predeterminations or preauthorizations, it would be beneficial in evaluating the claim for medical necessity if the records were attached to the claim.  Again, that letter went to a patient and those suggestions have never been sent to us directly.  I figure the reason for that is they don't really WANT the billing agents to know.  I also believe they really hope that the billers (whether it be a service or the physician/facility itself) will just send a claim, get a denial, and then transfer the balance to the patient for payment because the services weren't medically necessary or were "investigational" or "experimental."  

    DEFINITELY FIGHT THE FIGHT!  And to whoever (forgive me for not remembering because I read so many posts) had the idea to ask for the medical license and credentials and so on of whoever makes the determination to deny service:  THAT IS CLASSIC AND BRILLIANT!!!  In fact, I plan to start checking on that myself for our local "reviewer."  Just wish I had thought of it myself!  My hat's off to you!

    Oh...and another thing...make sure you know exactly how your MRI will be billed before you go in.  And it's perfectly fine to call the facility and ask.  What I mean is, does the facility bill everything globally (which is the technical component and professional components together) or do they bill the technical component and another separate billing service bills for the professional component?  (In case you don't know, the technical component is typically what the facility charges for "taking the image," use of staff, equipment, etc.  The professional component is the charge made by the radiologist who reads and interprets the MRI and then makes the report of his/her findings and diagnosis.)  If it is a global charge, find out what the total charge is (what is billed to the insurance carrier AND what your private pay discount total would be).  Make certain there are no other charges associated with the service.  If the technical and professional are billed separately, ask for each charge amount.  (They may have to refer you to the service who handles the professional component billing for that charge.)

    Someone also posted something about asking about a cash discount if your insurance doesn't pay or if you don't have insurance.  PLEASE do this.  I know we will reduce our fee for those who don't have coverage - and we don't require full payment up front.  We feel that our ladies already have enough to stress out about.  If they can pay it all up front, great...if not, we're happy to work with them.  I hope that any medical group working in this particular field will have a great deal of compassion and understanding and will do the same.  

    If the facility where you are planning to have the MRI isn't very accommodating to your requests for assistance (either with claim submission and appeals or discounts and payment plans), you can always go elsewhere.  

    Above all, please don't deny yourself the service.  It may be tough to have yet one more bill to take care of, but in the grand scheme of things, this is one bill that is worth it.  You will have either received what is hopefully an early diagnosis, or - more hopefully - found out that whatever suspicious spots that showed up on screening tests were nothing more than just that...spots.  Either way, it's good to know - early intervention or peace of mind.  Both are invaluable.

    One of my goals is to find ways (which for me means bugging people to no end - the media, insurance executives, Senators, Congressmen...the President, whoever) to make this a VERY public issue and to see what can really be done to get the stone age carriers to pay for these tests.  In the meantime, I am going to exhaust all means and travel all avenues with the carriers themselves to figure out what actually works to get claims paid.  

     I will keep you posted with any new discoveries!  

    Blessings to you all!

  • RadiologyBiller
    RadiologyBiller Member Posts: 2
    edited January 2009

    You might also want to check out your carrier's policy regarding a breast MRI.  If you cannot locate it on the website (usually under a physician tab/icon under a general link for Medical Policies - and you'll probably have to search), call the customer service center and ask them to direct you to the location of the written policy. 

    Here is the policy for BCBS of Oklahoma:


    Magnetic Resonance Imaging (MRI) of the Breast (BMRI)

    Effective Date:


    ILLINOIS: Illinois Joint Committee on Administrative Rules of the Administrative Code, Title 50: Insurance, Section 2016.30 - Required Coverage for Reconstructive Surgery Following Mastectomy

    NEW MEXICO: None

    OKLAHOMA: None

    TEXAS: 1997 Texas Department of Insurance (TIC Article 21.53I) Statute/Rule

    FEDERAL (applies to all Plans): Federal Law Women's Health and Cancer Rights Act (WHCRA) of 1998 (Title IX)


    Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.


    Magnetic Resonance Imaging (MRI) of the Breast (BMRI) may be considered medically necessary as an alternative to screening mammography in the following:

    * Patients considered to have a family history suggestive of hereditary breast cancer (multiple first-and/or second-degree relatives with breast, ovarian, or colon cancer; OR
    * Patients with a known BRCA-1 or BRCA-2 mutation; OR
    * To screen the contralateral breast in patients who have known breast cancer.

    BMRI may be considered medically necessary for diagnosis or detection in the following:

    * To evaluate the breast in patients with adenocarcinoma involving axillary nodes but with mammographically normal breast; OR
    * To determine ipsilateral tumor extent, and/or the presence of contralateral disease, in patients with newly diagnosed, clinically present localized breast cancer; OR
    * Before and after completion of neoadjuvant chemotherapy, to evaluate chemotherapeutic response and the extent of residual disease prior to surgical treatment; OR
    * To further evaluate suspicious clinical findings or imaging results that remain indeterminate after primary screening test results (mammography, breast ultrasound, biopsy) and physical examination are inconclusive for breast carcinoma or when these studies cannot be performed; OR
    * To evaluate suspected breast cancer recurrence in patients who have undergone post-mastectomy tissue reconstruction with tissue transfer flaps or implants; OR
    * To evaluate suspected breast cancer recurrence in patients with a prior history of breast cancer and inconclusive mammography, ultrasound and clinical findings.

    BMRI is considered experimental, investigational and unproven for all other indications, including but not limited to:

    * As a screening technique in average risk patients; OR
    * As a screening technique for the detection of breast cancer when sensitivity of mammography is limited (such as, dense breasts, breast implants); OR
    * For evaluation of low-suspicion findings on conventional testing not indicated for immediate biopsy and referred for short-interval follow-up; OR
    * To diagnose a suspicious breast lesion in order to avoid biopsy; OR
    * To further characterize indeterminate breast lesions identified by clinical exam, mammography or ultrasound when a biopsy can be performed; OR
    * For evaluation of residual tumor in patients with positive margins after lumpectomy; OR
    * To differentiate cysts from solid breast lesions; OR
    * MRI of the breast that does not use scanners equipped with breast coils, regardless of the clinical indications.

    BMRI to identify the status of a breast implant (regardless of breast implant age) placed for cosmetic reasons or for augmentation unrelated to breast cancer may be considered a cosmetic exclusion and will be subject to benefit limitations.


    CPT Codes: HCPCS Codes:

    77058, 77059



    ICD-9 Diagnosis Codes: ICD-9 Procedure Codes:

    174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, 175.0, 175.9, 196.3, 198.81, 233.0, 611.72, 996.54, V10.3, V16.0, V16.3, V16.41



    MRI is the use of a magnetic field and radio waves (instead of radiation) to produce detailed, computer-generated pictures of organs, body areas, or the entire body.

    BMRI can be performed using magnetic resonance (MR) scanners and intravenous MR contrast agents. Specialized breast coils are used to enhance the test outcome, which allows for bilateral breast imaging and greater differentiation of varying breast tissue. The patient is in a prone position with the breasts hanging through a cutout in the table. When MRI-guided biopsy of a lesion is planned, the patient may be positioned on her side to permit easier access to the breast for biopsy. The MRI-guided breast biopsy is accomplished using MRI-guide compatible needles and localization equipment. BMRI may also be called magnetic resonance mammography (MRM).

    Regarding risks of inheriting the susceptibility to breast cancer and use of BMRI, patients are evaluated for alterations or mutations in two genes, BRCA-1 and BRCA-2. These patients are of families suspected or confirmed as:

    * Having hereditary breast cancer,
    * Occurring at an early age,
    * In multiple generations or multiple first-degree relatives,
    * Occurring bilaterally, and
    * Occurring in a pattern suggesting an autosomal dominant pattern of inheritance (consistent with a high probability of harboring the breast cancer gene).

    Families at high risk for harboring a BRCA-1 or BRCA-2 mutation are those in which the incidence of breast cancer is found in first- or second-degree relatives, about half the family members are affected. The susceptibility may be transmitted through the maternal or paternal side of the family. The identification of BRCA-1 and BRCA-2 mutation makes it possible to test for abnormalities in these genes and gain information on the future risk of cancer. When faced with the risk of inheriting the susceptibility to cancer, patients with a positive test, a family history of breast cancer, or family members having a confirmed mutation of the BRAC-1 or BRAC-2 gene, may consider management options, such as BMRI.


    This policy regarding BMRI as a screening and/or diagnostic (detection) tool was primarily based upon several Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessments (BCBSA TEC Assessment).

    Screening Uses:

    For patients who are at high genetic risk for breast cancer - based on 2003 BCBSA TEC Assessment:

    * When applied to high genetic-risk patients, the evidence appears to show at least equivalent performance for MRI in terms in sensitivity in detecting breast cancer compared to mammography. In the studies reviewed, MRI detected 100% of cancer cases, while mammography detected 33%.
    * When applied to average-risk patients, the direct benefit of MRI screening among this population has not been proven. Because the prevalence of breast cancer is extremely low in average-risk patients, screening with a test such as MRI that has inferior specificity would result in lower positive-predictive values and many more false-positive results. Compared with mammography, there would be greater numbers of workups, biopsies, and morbidity if MRI screening were to be applied to average-risk women.

    For patients who have breast characteristics limiting the sensitivity of mammography - based on 2004 BCBSA TEC Assessment:

    * When applied to patients with or without a prior history of breast cancer, evidence is insufficient to draw conclusions on the effects of adjunctive BMRI on health outcomes.
    * When applied to patients in the average-risk population, the incremental effects of adjunctive BMRI screening are uncertain.
    * When the sensitivity of mammography is limited in patients after breast conservation therapy, there may be improvements in sensitivity with BMRI; however, more prospective studies are needed to confirm this.

    For patients who have breast cancer and desire screening of the contralateral breast - based on 2004 BCBSA TEC Assessment:

    * Several BMRI studies were conducted at various times before, during, and after treatment of breast cancer. Most studies reported that contralateral cancers detected on BMRI were not detected by conventional testing, whereas in some cases BMRI was done to evaluate suspicious findings in the contralateral breast. Four of five studies reported a 4% to 9% prevalence of cancer in the contralateral breast using MRI, with one study reporting a higher 24%. The positive predictive variable ranged from 20% to 80% and specificity ranged from 76% to 97%.
    * A larger study of 212 patients with negative findings on mammograms on the asymptomatic contralateral breast found 12 cancers (5%) on BMRI. However the positive predictive variable was 20% and specificity of 76%.
    * When the positive predictive variables and specificity for BMRI have not been well established, more confirmatory studies are necessary to support the use of BMRI in screening the contralateral breast.

    Diagnostic or Detection Uses:

    For patients who have a suspected breast implant rupture which had been originally placed for cosmetic reasons or augmentation (unrelated to breast cancer augmentation or reconstruction), whether clinical conditions appear or not, BMRI is not a covered benefit, as the initial breast implant placement was a cosmetic augmentation procedure. All services relating to the post-cosmetic augmentation procedure, including, but not limited to BMRI, are not a covered benefit.

    For patients who have a suspected breast implant rupture which had been originally placed for breast reconstruction resulting from a mastectomy due to breast cancer, accidental injury, or trauma, BMRI would be considered a covered benefit as mandated by Federal Legislation.

    For patients who have a suspected occult breast primary tumor with axillary nodal adenocarcinoma when there is a negative mammography and physical examination - based on 2004 BCBSA TEC Assessment:

    * The adjunctive use of BMRI allows patients to avoid the morbidity of mastectomy in a substantial portion of patients (approximately 25% - 61%) compared to the risk of an unnecessary biopsy estimated at 8%.
    * The use of positive BMRI findings to guide breast conserving therapy instead of presumptive mastectomy appears to offer substantial benefit of breast conservation in true-positive BMRI.

    For patients who have posteriorly located tumors and determination of chest wall involvement is required - based on clinical studies:

    * The available prospective study of 19 patients with posteriorly located breast tumors suspected to involve the pectoralis major muscle based on either mammography or clinical examination, the presence of abnormal enhancement within the pectoralis major muscle on BMRI was 100% sensitive and specific for identifying five tumors that actually had invaded the chest wall. In the available studies, the results of the BMRI were compared with surgical and pathological findings. Prior to the BMRI and based on clinical examination, thirteen of the 19 were thought to be fixed on the chest wall. When based on mammography, twelve of the 19 were thought to have pectoral muscle involvement.
    * The available evidence from two other studies reported four cases in which BMRI was able to determine involvement of the chest wall with 100% accuracy. Given the high level of diagnostic accuracy for BMRI, as compared with reference standard and conventional alternative techniques, the evidence is considered sufficient to permit conclusions that BMRI improves net health outcomes.

    For patients who have suspicious breast lesions and further characterization is desired - based on 2000, 2001, and 2004 BCBSA TEC Assessments:

    * The available studies addressed a group of patients who have breast lesions of sufficient suspicion to warrant recommendation to undergo biopsy for diagnosis. Therefore, BMRI results are assumed to have an impact on the decision whether or not to undergo definitive biopsy, considered the gold standard.
    * The available evidence did not show that this use of BMRI would improve health outcomes. Considering the relative ease of breast biopsy, the sensitivity of BMRI would have to be virtually 100% to confidently avoid biopsy. While BMRI performs well, it is clear that the sensitivity is not 100%. False negative results tend to occur, particularly in certain subcategories, such as ductal carcinoma in situ, but invasive carcinomas may fail to enhance on MR, leading to false negative findings as well. The potential harm to health outcomes of failing to diagnose breast cancer or at least delaying the diagnosis of breast cancer is of significant concern.

    For patients who have low-suspicion findings on conventional testing not indicated for immediate biopsy and referred for short-interval follow-up:

    * The available evidence suggests that adjunctive BMRI may be very sensitive and specific in patients with low-suspicion findings on conventional testing and may provide a useful method to select patients for biopsy or to avoid prolonged short-interval follow-up. However, none of the available studies use prospective methods in the appropriate patient population to directly compare the sensitivity and specificity of short-interval mammographic follow-up with BMRI and to determine the effects of adjunctive BMRI on cancer detection rate and biopsy rate.
    * Well-designed prospective confirmatory studies would be necessary to permit conclusions regarding the effect this adjunctive use of BMRI has on health outcomes.

    For patients who have clinically localized breast cancer and preoperative mapping to identify multicentric disease is desired - based on 2000 and 2004 BCBSA TEC Assessments:

    * The available multiple studies confirm BMRI has a better sensitivity for identifying multicentric breast tumors compared to mammography and/or ultrasound. Approximately 2% to 15% of patients otherwise eligible for breast conserving therapy may have multicentric disease seen on BMRI. BMRI is primarily used to identify multicentric breast tumors that have not been detected on conventional testing using mammography, clinical exam, or ultrasound.
    * The effect on health outcomes of multicentric disease detected only on BMRI has not been established. If BMRI information is used to guide mastectomy, then the potential benefit of breast conservation will be decreased. The effects of multicentric disease on locoregional occurrence and survival have not been established after either breast conserving therapy with whole-breast radiation or modified radical mastectomy.

    For patients who have locally advanced breast cancer and require preoperative tumor mapping before and after completion of neoadjuvant chemotherapy - based on 2004 BCBSA TEC Assessment:

    * Compared with conventional methods of evaluating tumor size and extent (such as mammography, clinical exam, or ultrasound), BMRI provides an estimation of tumor size and extent that is at least as good as or better than that based on alternatives. One clinical trial found BMRI to be 100% sensitive and specific for defining residual tumor after chemotherapy. Conversely, mammography achieved 90% sensitivity and 57% specificity, and clinical examination was only 50% sensitive and 86% specific.
    * Using BMRI instead of conventional methods to guide surgical decision-making regarding the use of breast conserving therapy versus mastectomy would be at least as beneficial and may more frequently lead to the appropriate surgical procedure.

    For patients who have locally advanced breast cancer and require evaluation of response during neoadjuvant chemotherapy - based on 2004 BCBSA TEC Assessment:

    * The available evidence is limited to a few small studies with inconsistencies in outcome measures, reporting, and use of statistical comparisons. A total of six studies, including a total of 206 patients, performed BMRI during the course of chemotherapy. BMRI outcomes for response to chemotherapy were based on either reduction in tumor size or reduction in contrast enhancement. Three studies reported negative-predictive value (ability to predict a nonresponsive tumor) results of 38%, 83%, and 100%. However, the two lower estimates were from prospective studies, while the highest estimate was from a retrospective review.
    * Results are not consistent, and there is insufficient evidence to determine whether BMRI can reliably predict lack of response to neoadjuvant chemotherapy. Ongoing clinical trials are pending.

    For patients who have positive surgical margins after lumpectomy and require evaluation of residual tumor - based on clinical studies:

    * Seven studies evaluated the diagnostic performance of BMRI to determine the presence of residual disease after prior biopsy or lumpectomy. Histopathology on re-excision was used as the reference standard. Most of these studies, including a single prospective study, reported poor sensitivity and specificity of BMRI for detection of residual disease. Two studies that reported more favorable results have methodological concerns that limit the influence of reported results. Three of the studies were conducted in the same institution and accrued patients during similar time periods, so overlap of reported patients may exist.
    * The available evidence is not sufficient to permit conclusions whether BMRI improves net health outcomes when used to identify the presence and/or extent of residual disease after lumpectomy and prior to re-excision.




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    Related Documents:
    MED207.110bu, Genetic Testing for Inherited Mutations or Susceptibility to Cancer or Other Conditions

    SUR716.009, Breast Implant, Removal and/or Insertion

    Policy History:

    Archived Document(s):

    Title: Effective Date:
    Magnetic Resonance Imaging (MRI) of the Breast (BMRI) 01-01-2007

    CPT® only copyright 2007 American Medical Association. All Rights Reserved.

  • abinneb
    abinneb Member Posts: 16
    edited January 2009

    Thank You!  Fantastic info! 

  • emanresu
    emanresu Member Posts: 13
    edited January 2009

    To OneBadBoob, prescribing medical treatment for a patient without having first examined the patient.

    Way to goooooooo!



  • anianiau
    anianiau Member Posts: 11
    edited January 2009

    A magnificent post, RadiologyBiller. Thank you.

  • cp418
    cp418 Member Posts: 359
    edited February 2009

    Mamhop - I thought that price sounded very high too.  I would expect in the $2000 plus range but I believe the hospitals may charge more.  Check these articles which quote $1000 - $2000.  I stopped getting my scans done at the medical center where I was treated when they tried to double bill me a few times after insurance already paid.  (They also wrote up my mammogram report wrong and got breasts switched - - so needless to say I don't trust them.)

  • samiam40
    samiam40 Member Posts: 93
    edited February 2009

    A couple points:  while I appreciate Radiology Biller's post as it contains lots of useful info, I have Anthem BCBS and my doctor's office did obtain precertifiation of my MRI from them.  The MRI was ordered for family history and dense breasts, and I had just had a negative mamm and u/s two weeks earlier.  I receved a copy of the written precert in the mail.

    Second, for those wondering about costs, the hospital billed $2,200 "globally" to BCBS.  I paid $534 which was the balance due on my $1,000 deductible for the year, and BCBS paid about $415.00.  The hospital must have written off the rest

  • diana50
    diana50 Member Posts: 253
    edited February 2009


    If your doctor orders an MRI you can assume that they believe you need to have one and it is medically necessary.  My oncologist usually has to talk to the physcian from the insurance company who regulates these scans. Previous scans, or mammos are often included because often times the radiaologsit will recommend futher testing; ie, MRI, ultrasound, etc.  I believe that in the recent years the insurance companies have become really tough on scans...but of recent breast MRI's are pretty much standard care; especially for women who have dense breasts.  It is becoming standard for your personal doctors to talk to the insurance companies.  Sad, but true. Always fight for what you need.  Call your insurance company if you need to.

  • ShelbyLyn
    ShelbyLyn Member Posts: 2
    edited February 2009

    I just had a digital mammogram done 01/29/09 and have been having mammograms since age 35 and now Im age 41. My mother died of breast cancer when she was in her early 50's and I have been trying to be cautious and take what steps I need to prevent myself from going through what she did. I received a call this week and my doctor's office told me that based on my mammogram they are recommending an MRI on both breasts. I also have dense breast tissue and some calcifications per mammogram. In 2005 I found a lump which ultrasound did not pick up and fortunatley it was removed and benign. Im scared to death of the what if's and not knowing. If they are recommending MRI I feel it must be needed. So at the same time the doctor's office told me based on your mammogram they want you to have an mri done on both breasts they also told me my insurance had denied it. The doctors office said they want to do it based on your family history and your dense breasts. So I am in the process of trying to deal with the insurance company and it is so frustrating. It is like you have know control over your own health. Im angry to think that someone is making decisions on my life. The doctors office said they made an appointment for me at a breast care center but that doesn't make me feel any better at the moment. It is so ridiculous that people have to go through this. Isn't early detection what it's all about and why testing is so important ?

  • KatherineA
    KatherineA Member Posts: 5
    edited February 2009

    This makes me so angry. The insurance company count on the fact  that most patients will just give up and pay the bill. Blue Cross Blue Shield turned me down after they had initially approved it. I was going through chemo for stage lllB and had cancer in both breasts! Same thing happened to my Chemo Buddy too.

    Find one person at your insurance company and always talk to them. Document everything, write down time and dates of all conversations. Write letters. Have your doctors write letters and keep copies of everything. Bug them.

    Good luck

  • ShelbyLyn
    ShelbyLyn Member Posts: 2
    edited February 2009

    Thanks Katherine, Im going to do what I can and write letters. Thank you so much for your response!

  • cp418
    cp418 Member Posts: 359
    edited February 2009
  • healthysofar
    healthysofar Member Posts: 4
    edited April 2009

     Well it looks like I found the right forum...

    BCBS is trying to deny my MRI from last summer also. Mine is a screening MRI since I am very high-risk (mom died age 29, 2 of her sisters bilateral early and aggressive) but I'm 42 and healthy so far.

    Their first denial said that I have "no specific family history to warrant it" - oh yeah they went there... When I disproved that the story changed to "experimental" so I now have to disprove that. Yes I even called ahead of time to see if it was covered - I was later told that that was no guarantee of coverage. 

    As annoying as this process is for me, I can't imagine how bad it would be to have BC at the same time and have to deal with this insurance company nonsense.

    When I need to smile about how bad insurance companies are I think of The Incredibles when Mr Incredible is telling the little old lady how to navigate the system because he knows the system is wrong - it's even better when he punches his boss through a few walls....

  • jlp
    jlp Member Posts: 3
    edited April 2009

    This is a little off topic, but also having an issue with BCBS...

    So far, BCBS has covered most of what's been submitted for my BC treatment, including pre-surgery MRI (same as many others here I have dense breast tissue - 4cm tumor not visible on mammo, sister with early BC also, so surgeon ordered bi-lat MRI to confirm there was a single tumor). I did get pre-certification. Thanks for all the good tips on getting future screening MRIs covered - I'm sure my BS will recommend them...

    Any way, when the bill ($27k) for my lumpectomy was submitted, it was denied automatically - reason "we don't have a signed statement on file to say you have no other insurance coverage" - I think this is chauvinist thinking - married woman with own primary insurance, huh, she must also be covered by her husband?  (Well actually we work for the same company so can pay a lot less for two separate individual policies than one family policy.) The insurance person I spoke to was actually quite nice and said she was surpised it was the only thing to be denied so far! Claim now going through for the second round....

    Keep up the good work in stopping these insurers from dictating our treatment!

  • fulloflife
    fulloflife Member Posts: 4
    edited April 2009

    all should call the whitehouse---they keep making 'preventative medicine' an issue but if insurance companies won't cover the tests to prevent disease then the WH should take issue with that, otherwise they should stop campaigning about preventative medicine