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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of her breast examination. Findings:  Three physician reviewer found that the enrollee has a complex breast history but is currently asymptomatic with respect to her breasts.  She was diagnosed with a right sided breast cancer, ductal carcinoma in situ.  She had a malignant stereotactic core biopsy and was followed by a right sided lumpectomy, though there is a notation that the lumpectomy was benign.  She then had an ultrasonically guided biopsy of the right breast which was also reportedly benign.  She also has a family history of breast cancer in a sister. The patient underwent a routine screening mammogram consisting of a synthetically reconstructed two dimensional views with three dimensional tomosynthesis study. The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or unstable areas of architectural distortion.  There was some right sided distortion, though this was felt to be related to her prior procedures. Her breast tissue was described as being average in density. The patient requested reimbursement for the breast tomosynthesis portion of the examination. The Health Plan denied reimbursement noting that the service at issue was investigational for evaluation of this patient. 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 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.  In this particular patient, the issue is how to best perform surveillance in a patient who has a past history of breast cancer. A study demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94%, and specificity increased from 20.7% to 74% when digital breast tomosynthesis (DBT) was applied. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis. DBT allowed unnecessary biopsy to be avoided in 37.3% of patients. Therefore, the addition of digital breast tomosynthesis was likely to have been superior to other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts 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.