Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for automated whole breast ultrasound for evaluation of the enrollee who had presented with dense breast tissue and inconclusive mammogram. Findings:  The 3 physician reviewers found that the medical studies have shown that annual screening mammography reduces mortality from breast cancer in women over the age of 40. The sensitivity of screening mammography in women with non-dense breast tissue is approximately 85%. However, this is significantly reduced in women with dense breast tissue by approximately 48 to 64%, as cancers can be obscured by the dense tissue. There is also an increased risk of breast cancer in women with dense tissue compared to non-dense counterparts. Therefore, screening ultrasound in this population is used to detect mammographically occult cancers. Specifically, automated whole breast ultrasound has been shown to have an increased sensitivity for cancer detection. Women with dense breast tissue are considered at intermediate risk for breast cancer. The American College of Radiology guidelines state that screening breast ultrasound can be used to detect more cancers in this population. The United States Preventive Services Task Force summary paper on additional screening for women with dense breast tissue states that the evidence suggests that more breast cancers will be diagnosed with the addition of ultrasound or magnetic resonance imaging in women with dense breast tissue. Moreover, most of these additional detected cancers are invasive cancers. Considering the above evidence that additional screening with ultrasound in the patient population with dense breast tissue will increase the sensitivity of invasive cancer detection, this patient would benefit from screening breast ultrasound. As such, automated whole breast ultrasound is likely to be more beneficial for the evaluation of the patients condition than the available standard imaging. Final Result: The 3 reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.