BlueCross BlueShield of Tennessee Medical Policy Manual

Magnetic Resonance Imaging (MRI) of the Breast

DESCRIPTION

Magnetic resonance imaging (MRI) is a non-invasive test using a multiplanar imaging method based on an interaction between radiofrequency (RF) electromagnetic fields and certain nuclei in the body (usually hydrogen nuclei) after the body has been placed in a strong magnetic field. The magnetic resonance (MR) scanners and intravenous magnetic resonance contrast agents are used to create detailed pictures of areas inside the body.

These images are intended to show the difference between normal and diseased tissue and to detected disease. MRI of the breast has been investigated as a screening tool in specific higher risk subgroups of individuals. Specialized breast coils are used during the imaging of the breast. MRI of the breast may be performed bilaterally or unilaterally. An MRI of the breast is not meant to replace mammography, percutaneous biopsy or ultrasound in the screening for breast cancer in the general population or to differentiate cysts from solid lesions.

POLICY

See also:

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The modified Gail model assesses risk for invasive breast cancer, accessible at http://www.cancer.gov/bcrisktool/.

High Risk Individuals are defined as individual with a 20% or greater lifetime risk of developing breast cancer as determined by the following:

The American Cancer Society, the Society of Breast Imaging, and the National Comprehensive Cancer Network (NCCN) Clinical Guidelines in Oncology recommend that breast MRI are performed in facilities that have the capability to perform MRI-guided breast biopsies.

BI-RADS™ Categories:

Breast MRI in the first 12 months after surgery has poor sensitivity and specificity due to post-surgical edema, hemorrhage, inflammation, scarring, and fat necrosis. It is advisable to wait 6 to 12 months after chemotherapy or radiation before performing breast MRI. MRI prior to this time may give misleading results, as cancers may exhibit benign appearing kinetics. Hormonal replacement (other than low dose) may have a significant effect on breast MRI enhancement patterns and specificity. If there is an unacceptable amount of physiologic enhancement on MRI, it may be necessary to stop hormone replacement for several months and repeat the MRI. It is unknown how hormonal therapy for breast cancer affects breast MRI.

SOURCES

American College of Radiology. (2014). ACR Appropriateness Criteria®. Evaluation of the symptomatic male breast. Retrieved August 19, 2016 from the National Guideline Clearinghouse. (NGC:010653)

American College of Radiology. (2014). ACR practice guidelines for the performance of contrast enhanced magnetic resonance imaging (MRI) of the breast. Retrieved May 21, 2015 from http://www.acr.org.

Antoniou, A.C., Casadei, S., Heikkinen, T., Barrowdale, D., Pylkäs, K., Roberts, J., et al. (2014). Breast-cancer risk in families with mutations in PALB2. The New England Journal of Medicine, 371 (6), 497-506. (Level 3 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2016). Magnetic resonance imaging of the breast (6.01.29). Retrieved May 9, 2017 from BlueWeb. (82 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2016). Moderate Penetrance Variants Associated With Breast Cancer in Individuals at High Breast Cancer Risk (2.04.126). Retrieved May 9, 2017 from BlueWeb. (71 articles and/or guidelines reviewed)

ECRI Institute. Health Technology Information Services. Evidence Reports. (January 2013) Noninvasive diagnostic tests for breast abnormalities: update of a 2006 review. Retrieved May 21, 2015 from the ECRI Institute.

Fernandes, P., Saam, J., Peterson, J., Hughes, E., Kaldate, R., et al. (2014). Comprehensive sequencing of PALB2 in patients with breast cancer suggests PALB2 mutations explain a subset of hereditary breast cancer. Cancer, 120 (7), 963-967. (Level 2 evidence)

Janatova, M., Kleibl, Z., Stribrna, J., Panczak, A., Vesela, K., Zimovjanova, M., et al. (2013). The PALB2 gene is a strong candidate for clinical testing in BRCA1- and BRCA2-negative hereditary breast cancer. Cancer epidemiology, biomarkers & prevention, 22 (12), 2323-2332. (Level 3 evidence)

National Comprehensive Cancer Network. (2016, December). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Genetic/familial high-risk assessment: breast and ovarian. Version 2.2017 Retrieved May 9, 2017 from the National Comprehensive Cancer Network website.

National Comprehensive Cancer Network. (2017, May). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast Cancer Screening and Diagnosis Version 2.2016. Retrieved May 9, 2017 from the National Comprehensive Cancer Network website.

National Government Services, Inc. (2016, October) Local Coverage Determination (LCD): Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (L33585) Retrieved May 10, 2017 from https://www.cms.gov/.

U.S. Preventive Services Task Force. (2014) Risk assessment, genetic counseling, and genetic testing for BRCA related cancer in women. Retrieved September 28, 2015 from: http://www.ahrq.gov/.

Winifred S. Hayes, Inc. Genetic Test Evaluation (GTE) Report. (2014, August) PALB2-Associated hereditary breast cancer. Retrieved September 28, 2015 from www.Hayesinc.com.

ORIGINAL EFFECTIVE DATE:  8/1/2001

MOST RECENT REVIEW DATE:  11/1/2017  

ID_BT & EC

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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