Dense Breast Tissue denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for automated whole breast ultrasound for evaluation of the enrollee who had presented with dense breast tissue and inconclusive mammogram. Findings: The 3 physician reviewers found that the medical studies have shown that annual screening mammography reduces mortality from breast cancer in women over the age of 40. The sensitivity of screening mammography in women with non-dense breast tissue is approximately 85%. However, this is significantly reduced in women with dense breast tissue by approximately 48 to 64%, as cancers can be obscured by the dense tissue. There is also an increased risk of breast cancer in women with dense tissue compared to non-dense counterparts. Therefore, screening ultrasound in this population is used to detect mammographically occult cancers.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for the enrollee, who presented for a breast examination. 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. No interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Benign appearing nodularity and scattered calcifications were seen. Her breasts were described as being very dense. The Health Plan has denied reimbursement for digital breast tomosynthesis used.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the bilateral breast tissue. There is limited evidence supporting the use of MRI screening for dense breasts rather than conventional mammography. According to one study, “The potential of MRI for screening women with dense breasts remains controversial because of the paucity of clinical evidence, the possibility of overdiagnosis, and the cost-effectiveness of the technique in this population.” In another study, researchers concluded that, “Harms of supplemental screening with ultrasound or MRI of women with dense breasts include higher recall and biopsy rates when compared with digital mammography alone.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for automated whole breast ultrasound. A peer-reviewed medical literature states that automated whole breast ultrasound is US Food and Drug Administration (FDA) approved for use in screening for breast cancer as an adjunct to mammography. Consistent with this recommendation, the bulk of available data favoring a clinical role for automated whole breast ultrasound supports its use with mammography, not as a replacement for mammography. This is due to the limitation on automated whole breast ultrasound in the detection of microcalcifications and evaluating the deeper portions of the breast. This patient underwent evaluation with an automated whole breast ultrasound in 2017 which did not detect any abnormality other than dense breasts.

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