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Mammography denials: what the review data shows
Independent reviewers have decided 784 published cases where an insurer denied Mammography — and they overturned the insurer 93.2% of the time. A denial for Mammography is a starting position, not a final answer.
Published decisions
784
2001–2026
Overturned
93.2%
731 denials reversed
Conditions behind mammography denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Female Breast Dis | 165 | 91.5% |
| Breast | 54 | 92.6% |
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 |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 774 | 93.5% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 10 | 70% |
Typical time to a decision
19 days
Most land between 13 and 21 days
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 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
Worth reading too — these show what an appeal has to overcome.
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.
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 treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Mammographywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
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.