Gordhandas S, Gellman C, Ingber S, Yen T, Kahn R, Kyana S, Taffuri A, Sokolowski S, Martinez D, Garcia P, Mullangi S, Long Roche K, Abu-Rustum N, Mangino D, Pilewskie M, Sutton E, Aviki E
Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America.
Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
Gynecol Oncol. 2025 Feb;193:20-23. doi: 10.1016/j.ygyno.2024.12.016. Epub 2025 Jan 3.
Women with germline BRCA1/2 pathogenic variants (gBRCA1/2) are recommended to undergo annual breast MRI and mammography. Our objective was to describe the frequency of insurance denials for annual breast MRIs in women with gBRCA1/2 and determine denial trends.
Women with gBRCA1/2 following in a high-risk breast cancer clinic with breast MRIs ordered from 2020 to 2021 were identified and cross-referenced with a database of insurance denials. Radiology records were queried to determine if screening breast MRIs were performed in 2020 and 2021. Rates of MRI denials and outcomes after appeal were determined.
There were 682 women with gBRCA1/2 who had screening breast MRIs ordered from 2020 to 2021, including 318 (47 %) BRCA1, 356 (52 %) BRCA2, and 8 (1 %) with both. 73 women (11 %) had an MRI denied. Women insured through Medicaid had the highest rates of denials (2020: 7 %, 2021: 18 %), followed by commercial insurance (2020: 6 %, 2021: 9 %). There were significantly more denials in 2021 compared to 2020 (p = 0.044), and 2021 denials were more likely to be denied on appeal. Of women with denials, 4 (14 %) in 2020 and 5 (11 %) in 2021 did not have a screening MRI performed. One patient with DCIS had an MRI denial prior to diagnosis.
Breast MRI insurance denials were present in 11 % of this high-risk cohort, and 14 % of women with denials did not undergo annual screening. There were significantly more denials in 2021, suggesting worsening barriers for these patients and added burden on providers to appeal for appropriate screening tests.
对于携带胚系BRCA1/2致病变异（gBRCA1/2）的女性，建议每年进行乳腺MRI和乳腺钼靶检查。我们的目的是描述gBRCA1/2女性每年乳腺MRI保险拒付的频率，并确定拒付趋势。
确定2020年至2021年在高危乳腺癌诊所就诊且已开具乳腺MRI检查单的gBRCA1/2女性，并与保险拒付数据库进行交叉核对。查询放射学记录以确定2020年和2021年是否进行了乳腺筛查MRI。确定MRI拒付率及上诉后的结果。
2020年至2021年，有682名携带gBRCA1/2的女性接受了乳腺筛查MRI检查，其中318名（47%）为BRCA1变异，356名（52%）为BRCA2变异。8名（1%）同时携带两种变异。73名女性（11%）的MRI检查被拒付。通过医疗补助保险参保的女性拒付率最高（2020年：7%，2021年：18%），其次是商业保险（2020年：6%，2021年：9%）。与2020年相比，2021年的拒付明显更多（p = 0.044），且2021年的拒付在上诉时更有可能被维持。在被拒付的女性中，2020年有4名（14%）、2021年有5名（11%）未进行筛查MRI检查。1例导管原位癌患者在诊断前MRI检查被拒付。
在这个高危队列中，11%的乳腺MRI检查存在保险拒付情况，14%被拒付的女性未接受年度筛查。2021年的拒付明显更多，这表明这些患者面临的障碍在加剧，也给医疗服务提供者增加了为适当筛查检查进行上诉的负担。
