Insurers Refusing MRI for Women at High Risk for Breast Cancer

Roxanne Nelson, RN, BSN

April 13, 2023

Women harboring BRCA 1/2 gene mutations are at high risk for breast cancer, and thus it's recommended they undergo annual breast MRI screening in addition to mammogram screening.

However, some women are finding that their insurer is refusing to cover the cost of the MRI.

A new study exploring this issue was presented at the recent Society of Gynecologic Oncology (SGO) 2023 Annual Meeting on Women's Cancer.

"Despite guidelines supporting annual breast MRI for screening in patients with gBRCA1/2, insurance denials were present in 11% of patients," said lead author Sushmita Gordhandas, MD, a gynecologic oncology fellow at Memorial Sloan Kettering Cancer Center, New York City. "In a high-resource setting, up to 14% of patients who were denied coverage did not undergo recommended MRI screening."

She also pointed out that the rate of denials was rising. "Compared to 2020, there were significantly more denials, and denials on appeal, in 2021," Gordhandas said. "This suggested worsening barriers and added burden on healthcare systems."

The addition of MRI to mammography is a standard recommendation for women with BRCA mutations, she pointed out, as it has been shown improve detection of early disease and decrease interval cancer development.

An expert not involved in the study noted that the recommendation for annual MRI screening in women at high risk for breast cancer is "substantiated by many publications, including multiple prospective clinical trials."

Linda Moy, MD, a radiologist at NYU Langone's Perlmutter Cancer Center and professor of radiology at NYU Grossman School of Medicine, New York City, noted that the American Cancer Society's Guidelines for screening breast MRI recommends annual breast MRI in women with a lifetime risk of greater than 20% — which includes women who are BRCA carriers — and recommends the screening begins at age 30.

"The lifetime breast cancer risk is 72% among BRCA1 and 69% among BRCA2 carriers," she said, adding that the "American College of Radiology also recommends for BRCA carriers to undergo annual screening MRI at age 30."

The National Comprehensive Cancer Network (NCCN) recommends that women at high risk for breast cancer undergo a mammogram and breast MRI every year starting at age 25 to 40, depending on the type of gene mutation, noted Gordhandas. "These guidelines are consistent with those from American College of Obstetricians and Gynecologists, the American Cancer Society, and the American College of Radiology," she added.

Denials Increased Over Time

For the study, Gordhandas and colleagues looked at the frequency of insurance denials for indicated breast MRI screening in women with germline BRCA1/2 pathogenic variants, and also looked at recent trends in denials over time.

The cohort comprised 682 women with BRCA1/2 gene mutations who were followed in a specialized high-risk breast cancer clinic, and who had breast MRIs ordered from 2020 to 2021. They were then cross-referenced with a database of insurance denials. Radiology records were also accessed to determine if screening breast MRIs had been performed in 2020 and 2021, and rates of MRI denials and results after appeals were determined. The rates between the two years were then compared.

The team found that overall, 73 women (11%) had an MRI denied. The median age of women who received a denial was 38 years, whereas those who had it approved was 44 years. "Patients with denials were significantly younger and more likely to be in the Medicaid population," said Gordhandas.

In 2020, 29 breast MRIs (5%) were denied, and on appeal, 8 (28%) were denied and 21 (72%) approved. The number of denials rose in 2021 but approvals remained the same; 45 breast MRIs were denied (8%); on appeal, 23 (51%) were denied, and 22 (49%) approved.

Thus, noted the authors, there were significantly more denials in 2021 as compared to 2020 (P = .044), and the denials in 2021 denials were statistically more likely to be denied on appeal (P = .045).

Among the women whose coverage was denied, 4 (14%) in 2020 and 5 (11%) in 2021 did not have an MRI screening performed. And within this group, 17 women (2.5%) received a diagnosis of cancer; 12 (1.8%) had invasive carcinoma, and 5 (0.7%) had ductal carcinoma in situ (DCIS). One patient with DCIS had an MRI denial prior to receiving her diagnosis.

"The top reasons given for denials were that they were outside the approved timeframe, authorization on file for a similar study, and that the clinician failed to show medical necessity," she explained.

Additional data are needed to establish a trend. "We are working to increase the approval timeframe, which is currently 45 days, and provide resources for the patient to deal with denials," Gordhandas added. "We also have to advocate for updates to USPSTF screening recommendations in high-risk patients."

Gordhandas reports no relevant financial relationships.

Society of Gynecologic Oncology (SGO) 2023 Annual Meeting on Women's Cancer. Presented March 28, 2023.

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