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Breast Cancer Screening: when insurers say no, reviewers often say yes
In 80 published external-review decisions involving breast cancer screening, independent physician reviewers overturned the insurer’s denial 92.5% of the time.
Published decisions
80
2001–2026
Overturned
92.5%
74 denials reversed
Most-fought treatments for breast cancer screening
What insurers denied — and how those fights ended.
| Treatment | Decisions | Overturned |
|---|---|---|
| Breast Tomosynthesis | 36 | 94.4% |
| Digital Breast Tomosynthesis | 34 | 97.1% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 75 | 96% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 5 | 40% |
Typical time to a decision
20 days
Most land between 13 and 21 days
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
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
Worth reading too — these show what an appeal has to overcome.
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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for breast cancer screening was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.