Heterogeneously 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 reimbursement for digital breast tomosynthesis performed. Findings: The physician reviewer found that the patient who was asymptomatic with respect to her breasts. On the date of dispute, the patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. In addition, the patient had an automated whole breast sonogram examination. The current images were compared to a prior mammogram dated six years prior, and no interval changes were noted on the mammographic portion of the study. There were no masses, areas of suspicious calcifications, or areas of architectural distortion on the mammogram.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed Findings: The physician reviewer found that the patient who was asymptomatic with respect to her breasts. On the date of dispute, the patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. The current images were compared to prior mammograms, and no interval changes were noted. There was evidence of a nodule which was described as benign-appearing, stable and smooth. Her breasts were heterogeneously dense. The Health Plan has denied reimbursement for the digital breast tomosynthesis portion of the examination on the date of dispute. Per the Health Plan, the service at issue was investigational for the evaluation of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging (MRI). The records provided for review document that this patient’s breast tissue on mammography was described as heterogeneously dense, not extremely dense. The patient was evaluated with targeted ultrasound and diagnostic mammogram which included coned compression spot films and were interpreted as negative. In addition, there are no increased risk factors for breast cancer delineated such as a strong family history or BRCA1 genetic mutation in the patient’s medical records. While small masses can be obscured by heterogeneously dense tissue, the same limitations of mammography that are present in extremely dense tissue are not present in heterogeneously 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 heterogeneously dense breast tissue, then check the rights and deadlines that apply to your plan.