Breast Mass 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 digital breast tomosynthesis for an annual breast screening examination. Findings: The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there are two separate indications for tomosynthesis. First, she has breasts that have been described as being dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this patient’s case, a mass as well as indeterminate calcifications were noted in the left breast. Breast tomosynthesis is an excellent means to better evaluate calcifications and identify masses that may not be apparent on routine mammography.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI). The available records indicate that the patient presented with a history of right breast mass. An ultrasound of the site of a palpable lump demonstrated an irregular hypoechoic complex cystic lesion with internal vascular flow with the track that extended nearly to the skin surface consistent with an inflammatory process such as an inflamed sebaceous cyst. The patient underwent evaluation with a breast MRI. The MRI demonstrated a right breast mass, BI-RADS Category 4 suspicious for malignancy. The National Comprehensive Cancer Network (NCCN) guidelines report that breast MRI is not recommended in the diagnostic evaluation of patients who present with a palpable mass in the breast.

A 56-year-old female enrollee has requested an MRI of the right breast for evaluation of her mass-like density in the upper outer right breast. Findings: Three physician reviewers found that this patient has an enlarging mass-like density within the right breast in the area of a prior benign breast biopsy. A diagnostic breast MRI has been requested for further evaluation. When a patient has a non-palpable mass that is suspicious, breast biopsy is the next appropriate study. The use of breast MRI to avoid biopsy is not medically appropriate. As noted by the American College of Radiology, MRI should not be used in lieu of biopsy of a mammographically, clinically, and/or sonographically suspicious finding. Breast MRI is not meant to be a substitute for a breast biopsy.

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