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 performed for the enrollee, who presented for a breast examination. Findings:  The 3 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 a combination two dimensional and three dimensional digital breast tomosynthesis examination. The current images were compared to prior mammograms. No interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Benign appearing nodularity and scattered calcifications were seen.  Her breasts were described as being very dense. The Health Plan has denied reimbursement for digital breast tomosynthesis used.  Per the Health Plan, the service at issue was investigational for the 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 patients breast tissue was described as being very dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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: 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.