Ductal Carcinoma In Situ denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 48-year-old female with a history of ductal carcinoma in situ treated with lumpectomy and radiation therapy in 1996. She experienced a recurrence and underwent a mastectomy in January 2004. Pathology findings are not included in the information provided. A PET scan in March 2004 showed uptake in the left axilla consistent with tumor. Based upon the submitted documentation, it is not known if this was documented pathologically. Nor is it known if the patient’s tumor marker was elevated at that time. She has received dose-dense adjuvant chemotherapy followed by Taxol. It has been indicated the patient’s tumor marker is rising.PET scans have broad utility in the management of multiple cancers. PET scans are of recognized value in restaging of relapsed breast cancers.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of her breast examination. Findings: Three physician reviewer found that the enrollee has a complex breast history but is currently asymptomatic with respect to her breasts. She was diagnosed with a right sided breast cancer, ductal carcinoma in situ. She had a malignant stereotactic core biopsy and was followed by a right sided lumpectomy, though there is a notation that the lumpectomy was benign. She then had an ultrasonically guided biopsy of the right breast which was also reportedly benign. She also has a family history of breast cancer in a sister. The patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study.

Where the denial was upheld

A 56-year-old female enrollee requested authorization and coverage for a magnetic resonance imaging (MRI) scan of the chest/breasts and a positron emission tomography (PET) scan. Findings: Two physician reviewers found that the patient had a positive biopsy for ductal carcinoma in situ (DCIS) and underwent an MRI of the breasts. In the right breast, the patient was noted to be status post lumpectomy and radiation changes with a new stereotactic staple within the 3:00 position. For this new area, an excisional biopsy was recommended and performed and the specimen was consistent with high grade DCIS. In addition, a PET scan was negative, with no noted pathologic hypermetabolic activity. A summary of the lumpectomy report states the size of lesion was 1.5 cm and high grade DCIS was identified, solid and cribiform type. No lymph nodes were noted to be present.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for DCISionRT genomic test. In this case, the patient has DCIS. In this clinical setting, the National Comprehensive Cancer Network (NCCN) guidelines on the management of breast cancer recommend breast conservation therapy, followed by whole breast radiation therapy, as a category 1 recommendation, meaning that it is supported by the strongest medical evidence. Alternative approaches such as accelerated partial breast irradiation after breast conservative surgery or not undergoing radiation therapy are category 2A recommendations, meaning that there is less medical evidence supporting these recommendations. In fact, there is a higher risk of developing invasive breast cancer if radiation therapy is not given.

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 ductal carcinoma in situ, then check the rights and deadlines that apply to your plan.