Three Dimensional 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 three-dimensional breast tomosynthesis for evaluation of her medical condition. Findings: Three 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.

Nature of Statutory Criteria/Case Summary: An enrollee requested three-dimensional (3D) breast tomosynthesis for medical evaluation of her medical condition. Findings: Three physician reviewers found that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patient’s medical condition than available standard modalities. There is support in the medical literature for the 3D breast tomosynthesis performed in this clinical setting. The medical literature reported the effect of integrated 2D and 3D mammography in population breast-cancer screening. The medical literature concluded that “Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. There is a lack of evidence in the peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising technology its clinical efficacy has yet to be substantiated in the peer-reviewed literature. As such, the services at issue were not likely to be more beneficial than standard modalities.

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