Bilateral Breast Tomosynthesis 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 bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: The 3 physician reviewers found that breast 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 dense breasts. In this patient’s case, her breast tissue was heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.

Nature of Statutory Criteria/Case Summary. An enrollee has requested bilateral breast tomosynthesis for the enrollee’s breast cancer screening. Findings: Three physician reviewers found that the patient has a family history of breast cancer. The patient underwent a routine screening mammogram consisting of a combination two dimensional (2D) and three dimensional (3D) tomosynthesis examination. The report noted that this study was the patient’s baseline mammogram, and no prior mammograms were available for comparison. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. The patient’s breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for bilateral breast tomosynthesis. 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 reimbursement for the bilateral breast tomosynthesis performed. Findings: The physician reviewer found that the patient who is asymptomatic with respect to her breasts. On date of dispute, she underwent a routine screening mammogram consisting of a three-dimensional tomosynthesis study with synthetically reconstructed two-dimensional views. The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as average in density. The patient has requested reimbursement for the bilateral breast tomosynthesis performed on date of dispute. The Health Plan has denied this request as investigational.

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that in this patient’s case, the services at issue were not likely to have been more effective than other alternatives. There is a lack of support for the bilateral breast tomosynthesis in this clinical setting. The medical records do not indicate an increased risk of breast cancer. Although breast tomosynthesis is a promising technique, the superior efficacy of bilateral breast tomosynthesis has not been established. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy. Therefore, the Health Plan’s denial should be upheld.

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 Bilateral Breast Tomosynthesis, then check the rights and deadlines that apply to your plan.