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Triple Negative Breast Cancer: when insurers say no, reviewers often say yes
In 13 published external-review decisions involving triple negative breast cancer, independent physician reviewers overturned the insurer’s denial 76.9% of the time.
Published decisions
13
2001–2026
Overturned
76.9%
10 denials reversed
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 8 | 75% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 80% |
Typical time to a decision
6 days
Most land between 4 and 20 days
Handled as urgent
61.5%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx comprehensive genomic profiling test. This patient has triple negative breast cancer that was advanced in presentation and is now metastatic. The records indicate that she is treatment-naïve and can expect a response from chemotherapy. The patient reportedly refused treatment with chemotherapy. Decisions regarding chemotherapy should consider patient preference, goals of treatment, the presence of toxicities from previous therapies, and the availability of alternative treatment options. In order to provide these options to this patient, the provider recommended mutational testing with FoundationOne CDx.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation, skull base to mid-thigh, and/or PET with CT for attenuation, skull base to mid-thigh. According to the American College of Radiology (ACR) criteria for monitoring response to neoadjuvant systemic therapy for breast cancer in a patient with known breast cancer and clinical suspicion for metastatic disease, PET/CT scan is considered usually appropriate. As noted by the ACR, for the purposes of staging and monitoring treatment response, PET/CT detects 50-100% of distant metastasis, with a specificity of 50-97%. In addition, multiple studies have demonstrated that PET/CT is particularly useful in the ongoing assessment of patients with triple negative breast cancer.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab). The U.S. Food and Drug Administration (FDA) has not approved Opdivo and Yervoy for the treatment of patients with triple negative breast cancer and this regimen is not supported by major drug compendia or the medical literature. Currently, the regimen of Opdivo and Yervoy is the subject of ongoing clinical trials. The current NCCN guidelines and peer-reviewed medical literature support treatment of metaplastic breast cancers similarly to other invasive breast cancers. Current data support therapies such as a PARP inhibitor, pembrolizumab, or Sacituzumab.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan. Findings: The physician reviewer found that The records provided for review document that this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable. Based on the available records, there is no current indication for a PET scan.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for triple negative breast cancer was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.