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Jan 26, 2009 12:23PM
CareCoreInternational unfortunately is now the company doing the pre-cerifications of MRI's for most insurance companies.
My MRI was also denied last week. I spoke with a supervisor several levels up and he gave me this criteria for their approvals of MRI's.
CareCore National Criteria for Imaging Version 3.200877058 MRI of the Breast Unilateral
77059 MRI of the Breast Bilateral 1-6
I. When necessary to confirm rupture of breast implants in asymptomatic
patients whose screening ultrasound shows rupture
II. Asymptomatic member 3 years after the placement of silicon implants
and every 2 years thereafter
III. To detect implant rupture in symptomatic patients whose ultrasound
shows no rupture
IV. To detect local tumor recurrence in breast cancer patients who have
undergone mastectomy and breast reconstruction with an implant
V. Patient with new diagnosis of breast cancer
VI. To detect local tumor recurrence in breast cancer patients with
radiographically dense breasts, or old scar tissue from previous breast
surgery that compromises the ability of combined mammography and
ultrasound ( A copy of the most recent mammography and ultrasound
reports must be submitted and the request referred for physician
VII. To detect the extent of residual cancer in the recently postoperative
breast with positive pathological margins after incomplete lumpectomy
when the patient still desires breast conservation and local re-excision
VIII. To detect and stage patients with Invasive Lobular Carcinoma (ILC)
for tailored therapy, especially when breast conservation is being
IX. To localize the site of primary occult breast cancer in patients with
adenocarcinoma suggestive of breast cancer discovered as axillary node
metastasis or distant metastasis without focal findings on physical
examination or on mammography/ultrasonography
X. To evaluate patients with high genetic risk of breast cancer
A. Patient is a confirmed carrier of BRCA1 * or BRCA2 gene mutations
B. Patient has a relative who is a confirmed carrier of the BRCA1 or BRCA2 gene mutation
C. Male relative with breast cancer
D. Gail model lifetime risk of 20% or more
E. One or more relatives with either 2 breast cancers or both breast and ovarian cancer
F. Family history of breast or ovarian cancer and Ashkenazi Jewish background
G. Personal or first degree relative with history of Li-Fraumeni syndrome
H. Personal or first degree relative with history of Cowden's syndrome
I. Personal or first degree relative with history of Bannayan-Riley- Ruvalcaba syndrome
XI. To evaluate patients with a high risk of breast cancer based on a
diagnosis of Lobular Carcinoma In situ (LCIS) 9,10
XII. History of radiation therapy to the chest between the ages of 10-30
XIII. Indeterminate breast imaging
A. Patients with indeterminate mammograms and sonograms if there is new onset of
1. Nipple retraction
2. Unilateral drainage from the nipple that is bloody or clear
B. All other requests for breast MRI based on indeterminate mammography and/or ultrasound
that do not meet the above criteria must be sent for physician review. All imaging reports
should be requested abnd available for the medical director to review. Only a physician may
approve a breast MRI on the basdis of abnormal mammography and or ultrasound.
XIV. Breast MRI for ANY of the following indications is not covered because
there is insufficient scientific evidence to support its use:
A. To confirm implant rupture in symptomatic patients whose ultrasonography shows rupture
especially with implants >10 years old (ultrasound sufficient to proceed with removal)
B. To screen for breast cancer
C. To evaluate breasts before biopsy in an effort to reduce the number of surgical biopsies for
D. To differentiate benign from malignant breast disease, especially clustered microcalcifications
E. To differentiate cysts from solid lesions (ultrasound indicated)
1. Berb, WA, Caskey CI, Hamper UM, et al, Single-and double-lumen silicone breast implant integrity: Prospective evaluation of MR and US
criteria, Radiology, 1995; 197:45-52.
2. Harris DM, Ganott MA, Shestak KC, et al, Silicone implant rupture: detection with US, Radiology, 1993; 187:761-768.
3. Important Information for women about breast reconstruction with INAMED silicone-filled breast implants, accessed at
www.fda.gov/cdrh/pdf2/P020056e... November 5, 2007.
4. Rankin SC, MRI of the breast, BJR, 2000; 73:806-818.
5 Lehman CD, Gatsonis C, Kuhl CK, et al, MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer, New
Eng J Med 2007; 356(13):1295-1303.
6. Saslow D, Boetes C, Burke W, et al, American cancer society guidelines for breast screening with MRI as an adjunct to mammography,
CA, A Ca J Clin, 2007; 57(2):75-89.
So, this fellow told me most MRI's are denied because the doctors do not word the request within these guidelines.
I am appealing.
But he actually told me it might be faster to have another member of my medical team make the request for a pre-certification of the MRI and make sure the wording fits into one of the categories that they will approve.
I cannot even believe this baloney. And all this for my $1,500 a month premium!!
Jane - Dance as if no one is watching!!
7/7/2007, IDC, <1cm, Stage I, Grade 1, 0/2 nodes, ER+/PR+, HER2-