Breast denials in California external review
In the California DMHC record, independent physician reviewers decided 808 published external-review cases involving breastand overturned the plan’s denial in 57.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for breast
| Category | Decisions | Overturned |
|---|---|---|
| MRI | 82 | 61% |
| Radiation Therapy | 61 | 52.5% |
| PET Scan | 56 | 73.2% |
| Mammography | 54 | 92.6% |
| Genetic Genomic Test | 53 | 71.7% |
| Proton Beam | 43 | 51.2% |
| Lab Work | 43 | 60.5% |
| Chemotherapy | 36 | 33.3% |
| Investigational Tx | 28 | 53.6% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 456 | 59% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 349 | 55.6% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 3 | 66.7% |
What the reviewers wrote
Where the denial was overturned
Physician 1The patient is a 55-year-old woman diagnosed with stage IIB (T2N1) breast cancer in June 2002. She was ultimately treated with a modified radical mastectomy and immediate reconstruction using a TRAM flap. Final pathology documented a 3cm (T2) grade III tumor with angiolymphatic invasion with 2/10 modes positive. The tumor was ER (+) PR (-) HER2/neu (-). The patient received six cycles of TAC adjuvant chemotherapy and hormonal therapy of letrozole. She also received Zometa as part of a clinical trial.In May 2004, the patient was found to have locoregional recurrence involving the supraclavicular nodal basin as well as a large chest wall recurrence with direct rib invasion. She was started on Xeloda therapy following staging studies of a CT chest and PET scan. On examination, the mass in the upper chest was noted to decrease in size and become softer.
Physician 1: The patient is a 53-year-old woman diagnosed with infiltrating lobular carcinoma in July 2000 and subsequently diagnosed with ipsilateral invasive ductal cancer in January 2005. She was found to have a 1.4cm tumor with positive estrogen receptors and negative axillary nodes. The patient underwent an Oncotype DX assay and had a recurrence score of 17 which predicts an 11% chance of recurrence if the patient is not treated with chemotherapy. On that basis, the decision was made to forgo adjuvant chemotherapy.
Where the denial was upheld
Physician 1The patient is a 51-year-old woman who was diagnosed with left breast cancer in December 2003. At that time she was found to have a 1.3cm invasive ductal carcinoma with two positive nodes, one of which apparently was palpable to the surgeon. She has been treated with adjuvant chemotherapy including Adriamycin, Cytoxan, and Taxotere. Since her surgery was a segmental mastectomy, she now requires radiation therapy to the breast.The patient has been seen by radiation therapy who discussed the technique of whole breast radiation, including possible toxicities. It has been proposed the patient receive radiation only to the area of the tumor, using intensity-modulated radiation therapy (IMRT).It is standard and advisable for women who undergo less than a mastectomy to undergo radiation therapy to the breast.
Physician 1: The patient is a young woman with breast cancer with a very high risk of relapse based on persistently positive lymph nodes after induction chemotherapy. She has had PET imaging as follow-up in 2002 and 2003. The patient wishes to undergo further PET imaging. She has no localizing symptoms or findings. Based upon the records provided, other imaging has not been performed recently. The Health Plan has denied coverage for the requested PET scan on the basis it is considered investigational in this clinical setting. PET scanning is not indicated as a screen for recurrent cancer in this setting. It is only questionably more sensitive and specific than other modalities. In addition, treatment would not be based on a PET scan alone (other imaging and biopsies would be needed).
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving breast, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY