Breast Cancer Screening denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for the enrollee, who presented for breast cancer screening. Findings: The 3 physician reviewers found that The patient is a female who was asymptomatic with respect to her breasts. She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional digital breast tomosynthesis examination. The current images were compared to prior mammograms, and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as being heterogeneously dense. It was recommended that the patient consider automated whole breast sonography. The Health Plan has denied reimbursement for breast tomosynthesis performed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollee’s breast cancer screening. Findings: 2/3 of the physician reviewers found that the patient is asymptomatic with respect to her breasts. She has a family history of breast cancer, and a cousin. In addition, the patient has had a prior core biopsy of her right breast, which was benign. She also has had a prior augmentation mammoplasty. She underwent a routine screening mammogram consisting of a three-dimensional (3D) tomosynthesis study with synthetically reconstructed two-dimensional (2D) views. In addition of routine views, implant displacement views were also obtained. The current images were compared to prior mammograms and no interval changes were noted.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral magnetic resonance imaging of breast, without and/or with contrast.MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. It is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor, but that a follow-up MRI is recommended. Questionable MRI findings often lead to unnecessary biopsies. Additionally, there are cases where an MRI has not detected a breast cancer (false negative). There is little evidence to support the use of MRI as a surveillance tool rather than conventional mammography.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for MRI in both breasts. The American College of Radiology (ACR) Appropriateness Criteria note that in the context of a palpable mass, there is little role for advanced technologies such as MRI, positron emission mammography, or molecular breast imaging in the evaluation of a palpable mass. Rather, when a suspicious finding is identified, biopsy is indicated.

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 cancer screening, then check the rights and deadlines that apply to your plan.