Digital 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 digital breast tomosynthesis that were performed for the evaluation of the enrollee, who presented for breast examination. Findings: Two physician reviewers found that the patient was asymptomatic with respect to her breasts. She had a prior left breast biopsy. She underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views. Those images were compared to prior. In one image there was an area of asymmetry noted in the left breast. In addition, there was a nodular area noted in the retroareolar area of the right breast. Following that screening study, it was recommended that the patient return for additional imaging. The patient’s breasts were described as heterogeneously dense.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis that was performed for evaluation of the enrollee, who presented for a breast screening mammogram. Findings: 2/3 of the 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 two dimensional conventional views. That study was compared to prior mammograms, and it was noted that there was a new nodule in the axillary tail of her left breast, and additional imaging was recommended. At that time, her breasts were described as having scattered fibroglandular densities. Subsequently, she returned for a diagnostic left sided study and she had a combination two dimensional and three dimensional tomosynthesis study of her left breast.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollee’s risk for breast cancer. Findings: 2/3 of the 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, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved. That is, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollee’s risk for breast cancer. Findings: 2/3 of the 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, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient does not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. The 2D images were reconstructed from the primary tomosynthesis acquisition, thus a routine mammogram would have been sufficient.

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