Practice guidelines for MRI surveillance for long-term follow-up

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(1) notesnet.carefirst.com Open Doc  < provider.carefirst.com search on query=mri+breast*&amp
MRI of the breast is considered medically necessary for the following indications for screening for breast cancer in the following high risk patients:
  • with a known BRCA1 or BRCA2 mutation; or
  • a high-risk of BRCA1 or BRCA2 mutation, due to the known presence of the mutation in first or second-degree relatives (male or female); * or
  • who have Li-Fraumeni syndrome or Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome or who have a first-degree relative with one of these syndromes, or
  • at high risk (20% or greater lifetime risk) of developing breast cancer as identified by model ** that are largely defined by family history, or
  • in conjunction with mammography for women with a lifetime risk >20% based on a history of lobular carcinoma in situ (LCIS) or atypical ductal hyperplasia (ADH)/atypical lobular hyperplasia (ALH) or
  • who received radiation therapy to the chest between the ages of 10 and 30 years of age.
Does not include men in Tennessee BCBS?
Women with history of radiation to the chest between ages 10 and 30. (If history of Hodgkin’s Disease, breast screening should start 8 to 10 years post-therapy, or at age 40,...

https://www.anthem.com/medicalpolicies/policies/mp_pw_a053263.htm
http://www.aetna.com/cpb/medical/data/100_199/0105.html

(1) MRI of the breast for routine screening purposes, is considered experimental / investigational, as it does not meet TEC criteria # 2 - 5.
MRI of the breast for all other conditions is considered not medically necessary.
* NOTE: First-degree relatives includes the patient's parents, full siblings, and children. A second-degree relative includes the individual's grandparents, grandchildren, aunts, uncles, nephews, nieces, and half siblings.
** Examples of models used in estimating risk and that utilize family history include the Claus, Tyrer-Cusick and BRCAPRO models (see References, Claus, et al; Parmigiani, et al; Tyrer, et al).