Providers chart uptick in number of breast MRI denials issued by insurers

Insurers are increasingly issuing denials for coverage of vital breast MRI exams, according to a new study out of Memorial Sloan Kettering Cancer Center.

Providers at the noted New York-based institution had noticed a recent trend in refusals for such scans. They set out to better understand the problem, querying radiology records for exams performed at a specialized breast cancer center in 2020 and 2021 (as far back as their data go).

They specifically targeted women with germline BRCA1/2 mutations, who are at an increased risk of developing breast cancer. Among nearly 700 women who were positive for this concern, 11% experienced an MRI denial, researchers reported recently at the Society of Gynecologic Oncology’s Annual Meeting on Women’s Cancer.

“Putting it into context, MSK is an institution that has a lot of support to help patients overcome these insurance barriers,” Emeline Aviki, MD, MBA, a GYN surgeon and head of the hospital’s affordability working group, told Radiology Business. “And so, our thoughts were: If this is happening here, it’s occurring multiple-fold elsewhere.”

Women who faced denials were a median age of 38 and ranged from 25 to 65 years old. Medicaid was the largest offender, denying 7% of breast MRI requests in 2020, which leapt to 18% the following year among an already-vulnerable population. Commercial insurers came in second, denying 6% of requests in 2020 and 9% the following year. More concerning, 14% of denied patients never received the MRI exam.

Insurers cited three common reasons for the majority of denials. Those included that the exam occurred outside of their stated 45-day timeframe following approval, there was already an authorization on file for a similar imaging study, or the provider failed to demonstrate medical necessity.

This trend continues despite recommendations from institutions such as the National Comprehensive Cancer Network that suggest annual breast MRIs on most women with germline BRCA1/2 mutations are necessary. The modality has a greater sensitivity for detecting the disease in this high-risk population, yet previous analyses have shown that insurers do not fully cover upward of 75% of breast MRIs for this group.

Currently, the U.S. Preventative Services Task Force lacks specific recommendations tied to breast MRI. MSK experts urged others to advocate for a change at the USPSTF to begin addressing such denials.

“Just bringing attention to this issue because patients don’t always bring it up,” Sushmita Gordhandas, MD, a gynecologic oncology fellow at MSK and leader of the study, told Radiology Business. “Financial stuff is always difficult to talk about. So, unless we ask and try to make things better for our patients, they might not even tell us. Shining a light on this topic is helpful.”

MSK experts also suggested collaborating with payers to reduce unnecessary denials and cumbersome prior authorizations. The institution is currently working with insurers to try and extend the 45-day timeframe for completing a breast MRI after a payer grants its approval. They’re working with patients, too, to provide resources for appealing following a rejection.

“At MSK, we have a lot of teams that can help in these circumstances, and so, a lot of times it doesn’t end up affecting the patient directly,” Gordhandas added. “But they still get that letter saying that something was denied, which can be frustrating for them.”

Aviki and Gordhandas cautioned that their analysis is limited by its small sample size and short timeframe. They hope to submit the study for publication in a peer-reviewed medical journal.

Marty Stempniak

Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic. 

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