Insurance coverage for MRI if family risk

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cp418
cp418 Member Posts: 7,079
edited June 2014 in High Risk for Breast Cancer

I'm posting this question for a friend.  Her mother was dx with bc stage 1 at age 74 and her sister was recently dx with bc age 48 stage 2.  Some doctors have mentioned BRCA testing but the family has not pursued for insurance covage issues.  Now my friend would like to get a baseline MRI as she has hx of breast biopsies identified as cysts with slight dense breasts and age 50 premenopause.  One doctor said she can not get the insurance coverage for the MRI without getting the BRCA testing done first even with her family hx.  Has anyone encountered similar resistance to get baseline MRI if your mammogram was clear?

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  • otter
    otter Member Posts: 6,099
    edited August 2008

    Yes.  In fact, I still can't get an MRI for screening purposes, even though I've had BC, and digital mammography failed to detect my tumor (my breast tissue is very dense).

    There are a few specific situations in which insurance companies will cover a breast MRI without fussing.  I think one of those situations is if someone has a documented familial risk factor--generally, BRCA+.  I was tested for a BRCA mutation, and my insurance paid for the testing.  (Fortunately, I'm negative:  no mutations in BRCA1 or BRCA2.)

    otter 

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  • hollyann
    hollyann Member Posts: 2,992
    edited August 2008

    cp, due to family history I had no problem getting my insurance to cover my MRI, which is how my bc was found by the way...It was undetected by mammo but something was seen onultrasound thus the MRI.....Good luck to your friend and her mother...Hugs..

    Lucy 

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  • Jeansbeans
    Jeansbeans Member Posts: 175
    edited September 2008

    Hi cp418, Tell your friend she will have to FIGHT, Fight, FIGHT for her MRI. Ins. Co. don't want to pay, But if you get persistant and call plus have Dr. write letter and call she may get results. Make sure they know the strong family history.  I am now the 4th generation with BC. MY mom, my Grandmother and Greatgrandmother!  I am 54 now, But at 53 I fought for a MRI because all of the women in my family who had BC were  in their early 50's. So, after 3 months and 2 denials, they finally approved an MRI. Good thing too!  I had a mammo and MRI done the same day.  MY mammo was clean and my MRI showed 2 areas of cancer.So,  in May I had double mast. with tissue expanders placed.  Because  the bc was caught so early, no nodes, I am blessed to not need Radiation or chemo, just tamoxifen for 5 yrs.  I also had the genetic testing done to see if I carry the gene, I DO NOT!  MY INs. paid for that test!  It cost about $3300. if you have to pay put of pocket. Then, If  there are children, they can have the testing done for around $ 330.00.  Be your own advocate and fight for a MRI!!  Talk to a supervisor or Medical director of your INS. Co. Don't take NO for an answer.  WE women need to push for MRI's. they detect the cancer so much earlier. Good Luck . Keep us posted. Jeanie

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  • JStar
    JStar Member Posts: 30
    edited September 2008

    Jeansbeans, the American Cancer Society's current guidelines recommend annual breast MRI screening in women whose estimated lifetime risk exceeds 20%.  My doctor at Mayo used the GAIL model to determine the lifetime risk.  You can find this online, it's very simple and only asks 6-8 total easy questions.  I suppose that just because the Cancer Society suggests this, an insurance company can still balk - but mine didn't.  So if the risk exceeds 20%, they have a great case to present to the ins co.  As for your friend's family not wanting the BRCA gene testing done, I was under the impression that insurance co's couldn't discriminate because of that but could totally be wrong about...  Also, very good news on the breast cancer detection-front with a method called "MBI" which is as sensitive as an MRI but as easy as a mammogram.  This was developed by doctors at Mayo who wanted to offer the dependability of an MRI without the cumbersome equipment.  It's been in the news a lot lately, so let's keep our eyes and voices open.  All the best to you and your friend (and her family).  JStar  

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  • tykikibuds
    tykikibuds Member Posts: 7
    edited September 2008

      Thanks for the great advice! My sister (2x bc survivor BRCA+) just sent this forum to me because I am going through the same frustration. Two days ago I had a cyst finding on my mammo and I've had 6 biopsies prior to that starting at 16 yrs. old. We also have 4 generations of bc/ovarian cancer and 3 BRCA+ family members. Last year I asked my Dr. for a MRI and she said she would write an order for anything that I wanted but she didn't think my insurance would cover it. It's sooo frustrating, I have people telling me (even genetic counselor) that I fit the guidelines then when I get in front of my Dr., she balks. Right now I am to the point that if I have to pay for it myself, I'm going to have to do that. Do you know if you can make payments?!? lol  With my sisters help, I've printed out papers to help my case, did the assessment tool (42.6) and I will be asking my Dr. to write a letter. I see her in a couple of weeks, so wish me luck and if you can think of anything else please let me know. Thank you Jeansbeans, JStar and last but not least, my fav sister!

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  • JStar
    JStar Member Posts: 30
    edited September 2008

    tykikibuds, I do wish you luck. And understand your gratitude to your sister who is encouraging you to be proactive. My sister - 12 yr bc survivor even with several positive lymph - is the same way, so encouraging.  It sounds like your doctor is being very sensitive to the possibility of this being out of pocket for you, which is very nice, but you need her to be confident and more agressive. When my ins co got the bill for the MRI, what they asked for was my dr's clinical notes indicating my lifetime risk (47% GAIL score, but some other models put me as high as 82%, and this is without the known genes). I'm currently consulting surgeons for prophylactic bilateral mastectomies, a total personal choice and not for everyone. My sister, who now has primary pancreatic cancer (apparently unrelated to breast as she is negative for brca1 and 2 - unless there is a brca3 or 4 that we don't know about yet), is all for me avoiding everything she's been through. I love her so so much.  I wish you luck and have just said a prayer for you as well. If nothing else, consider getting a doctor appt with someone at a larger center that is more aggressive in their approaches, and they will be more apt to fight for your right to an MRI.  Take care!  JStar

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  • leaf
    leaf Member Posts: 8,188
    edited September 2008

    Ha- I have LCIS and ALH, and a weak family history.  If you ignore my LCIS and stick my numbers into the Gail model, you get >20%.  I went for a consult at a major university (NCI certified) and they recommended NO MRI, even for a baseline, because 'I have too much scar tissue.'  I can't even get the major university to FIND my consult with them and send them to my onc!!

    The 2007 ACI guidelines say that MRI for SCREENING is in a gray zone except for BRCA, and unusual things like therapeutic chest radiation for Hodgkins, some unusual genetics, etc.

    http://caonline.amcancersoc.org/cgi/content/full/57/2/75 

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  • tykikibuds
    tykikibuds Member Posts: 7
    edited October 2008

      I had my visit today for my annual exam. My regular Dr. who I have seen for 15 yrs. wasn't in on my days off work so I had to see the NP. I went in with my paperwork prepared to do battle to get a MRI. When I get through explaining everything to the NP, who I've never seen, she says, yes, yes, you need one, and by the way, your 2007 mammo seriously recommended  that you have a breast MRI. It also had a note beside it saying "Patient aware" signed by my Dr. I can tell you THIS patient was never made aware and my Dr. KNEW I wanted one and she never called me with that recommendation. I'm really aggravated with my Dr., I thought we had a good working relationship. The NP I saw today called the breast center to set me up for the breast MRI that I should have had a year ago. I know all of this still doesn't mean my insurance co. will cooperate with paying for it, but with this recommendation from the Radiologist, I would hope it would help my case.  

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