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 has a history of a prior augmentation mammoplasty.  She underwent a routine screening mammogram consisting of a three dimensional tomosynthesis study with synthetically reconstructed two dimensional views.  There were no prior mammograms available for comparison.  In addition to routine views, implant displacement views were obtained.  On the implant displacement views, there was evidence of a 3 mm nodule in the upper outer quadrant of the right breast as well as a 6 mm area of asymmetry in the lateral aspect of the left breast. Her breasts were described as being average in density.  Following the study, it was recommended that she return for a diagnostic mammogram as well as a breast ultrasound. The Health Plan denied coverage for the tomosynthesis portion of the examination stating that breast tomosynthesis 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, her breasts were not especially dense.  However, a nodule was noted in one breast, and there was an area of asymmetry in the other breast. Tomosynthesis has been shown to be valuable in better delineation and identification of small breast nodules.  The ability to separate the nodule and confirm asymmetry is best performed with tomosynthesis than with routine mammography. In sum, digital breast tomosynthesis performed 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.