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 breast tomosynthesis for the enrollee, who presented for breast cancer screening. Findings: The 3 physician reviewers found that The patient is a female who was asymptomatic with respect to her breasts. She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional digital breast tomosynthesis examination. 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 being heterogeneously dense. It was recommended that the patient consider automated whole breast sonography. The Health Plan has denied reimbursement for breast tomosynthesis performed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested peripheral bone mineral density (BMD) testing and breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy. Breast tomosynthesis is U.S. Food and Drug Administration (FDA) approved as an adjuvant method of screening along with traditional mammography. In the screening setting, tomosynthesis helps to decrease recall rates by delineating true lesions from spurious lesions caused by overlapping structures seen on routine mammography.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer. Two 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that there is insufficient support for the services at issue in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improve breast cancer detection and have the potential to reduce false positive recalls. However, in this particular patient, the submitted documentation does not indicate that there were problems to be resolved.

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