Breast Pain 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 performed for the evaluation of the enrollee’s medical condition. Findings: Three physician reviewers found that the patient had a two month history of right breast pain. She underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. There were no prior images for comparison. In addition to the mammogram, she had a targeted sonogram of her right breast. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient.

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis performed for evaluation of her breast pain. Findings: Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates when tomosynthesis has been added to the usual screening mammography protocol, the addition of the technique has gained worldwide support among providers due to an associated significant decrease in callbacks and increased detection of small cancers. This advantage is due to the tomographic quality of digital tomosynthesis and the advantage of having the ability to eliminate the confusion and artifact of glandular breast tissue either mimicking or obscuring a mass. Thus, the addition of the technique is considered more beneficial for the patient than mammography alone.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for removal of bilateral breast implants with bilateral mastopexy (breast lift) for treatment of the enrollee who has had a history of left breast pain. Findings: The physician reviewer found that based on the medical documentation for this review, the patient appears to have a possible complication from a cosmetic procedure, in which her volume of augmentation was excessive. She has undergone physical therapy, but appears to continue to complain of pain. However, the plastic surgery documentation does not support that her enlarged breast size is the source of the pain, but is more likely due to her history of the motor vehicle accident.

A 53-year-old female has requested coverage for a past bilateral breast MRI for evaluation of her breast pain. Findings: The physician reviewer found that this patient presented with right breast pain with a history of breast implants, and no breast abnormalities were noted on physical examination. She was referred for a breast MRI as a screening study for breast cancer and also as a diagnostic study to evaluate the patient’s right breast pain. Per the submitted records, the patient did not undergo a recent mammography or breast ultrasound prior to the MRI study. Patients who have breast implants can safely undergo mammography, and mammography is the gold standard for screening of breast cancer and to evaluate breast abnormalities and/or breast symptoms. The indications for a screening breast MRI are well-established in the peer-reviewed medical literature.

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