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 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. In addition, she had a dedicated left breast sonogram.  The studies demonstrated focal asymmetry and a well circumscribed mass in the two oclock position of her left breast.  The sonogram revealed that this was an intramammary lymph node. The Health Plan has denied reimbursement for digital breast tomosynthesis portion of the examination performed. 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 patient demonstrates the optimal use for tomosynthesis.  She initially had a routine two dimensional mammogram, which would have minimized her radiation dose.  A questionable nodule was then identified, and it was recommended (as is commonly done when a previously unsuspected mass is discovered on a screening study) that she return for additional imaging.  Those additional images were augmented by the tomosynthesis, which clearly defined the abnormality and the benign nature was confirmed on sonography.  Tomography is often invaluable in better characterizing a mass by better defining its margins. The ability to separate out the overlapping structures enables the possibility of better demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2/3 of 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: 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.