Heterogeneously Dense Breasts 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 digital breast tomosynthesis (3D mammogram).The main weakness of mammography is the detection of cancer in women with radiographic dense breasts. While nearly all cancers will be apparent in fatty breasts, only half will be visible in extremely dense breasts. This is a result of the masking or camouflaging of non-calcified cancers by surrounding dense tissue. An advantage of tomosynthesis is better delineation and characterization of breast masses. The primary benefit of digital breast tomosynthesis would be expected to be for non-calcified mammographic findings, such as masses, asymmetries, and distortion. In the most basic application, digital breast tomosynthesis would allow visualization of cancers not apparent by conventional mammography, thus improving sensitivity.

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for her breast examination. Findings: Three physician reviewers found that 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 (CT) 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 the dense breast. In this particular patient, she was noted to have heterogeneously dense breasts. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.

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