Dense Breast 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 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. It was stated that this patient has dense breasts as well as scattered benign nodules. It is specifically those patients who have dense breasts that can benefit most from digital tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.

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 Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support cited above, the breast tomosynthesis was likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy.

Where the denial was upheld

A 64-year-old female enrollee requested bilateral breast magnetic resonance imaging (MRI) for medical evaluation of the enrollee’s dense breasts. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure. This patient has a family history of breast cancer with at least one first-degree relative with the disease. Her breast tissue is heterogeneously dense on mammography. However, the current medical evidence does not support the requested diagnostic procedure in this clinical setting. While MRI is the most sensitive means with which to detect early breast cancer, this technique is medically necessary when there is a greater than 20% lifetime risk of breast cancer or when there is BRCA genetic mutation.

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