I Have Been Told I Have Dense Breasts, What Should I Do?
1. What are other breast screening tests after my mammogram?
For women with dense breasts, an additional breast screening test after a mammogram may find cancer not seen on the mammogram alone.
Like a mammogram, each type of additional screening has benefits and things to consider. For instance, there is the possibility of being “called back” or “recalled” for more images and sometimes a biopsy. About 1 in every 10 women having a screening mammogram will be called back for extra views or tests to look at an area of the breast more closely. Any additional screening test may also result in a call back. Talk to your health care provider about which one of these tests is right for you.
Out of 1,000 women, about 15 can be diagnosed with breast cancer each year:
- About 5 women will be diagnosed with breast cancer found on their screening mammogram. This means about 10 women will have a cancer missed by their mammogram.
- To identify those 10 women who have breast cancer, an additional breast screening test can be done. Any additional breast screening test may find cancers and also things that look concerning, but that turn out not to be cancer (false alarms).
Cancer Detection by Screening Test
|If 1,000 Women Are Screened With:||Number of Women Found to Have Cancer|
|2D mammogram alone||5|
|3D mammogram (tomosynthesis)||6*|
|Most Common Additional Screening Tests|
|Mammogram PLUS ultrasound (sonogram)||8|
|Mammogram PLUS contrast-enhanced MRI||15|
|Other Additional Screening Tests|
|Mammogram PLUS Molecular Breast Imaging (MBI)||12|
|Contrast-enhanced mammogram (CEM)||15
Rev. March 2022
More to Know About Screening Tests After Your Mammogram
Ultrasound is the most common additional test used after a mammogram. Ultrasound uses sound waves and does not involve radiation or an injection into your vein. Gentle pressure is applied to the breasts and rarely causes discomfort. An Ultrasound test takes about 15 to 20 minutes.
If 1,000 women have an Ultrasound:
- 30 women will have something found on their Ultrasound test and will be recommended to have a needle biopsy (where a small sample of your breast tissue is taken and checked for cancer).
- 2-3 cancers will be found that were not seen on the mammogram.
Magnetic resonance imaging (MRI) involves an injection of a gadolinium contrast solution into your vein that may feel a little cold while it is injected. You lie on your stomach and your breasts fit into two openings. The contrast-enhanced MRI is done in the tunnel of a large magnet. The magnet makes loud noises while images are made. Contrast-enhanced MRI does not use radiation and takes from 10 to 25 minutes.
If 1,000 women have an MRI:
- 50 women will be recommended to have a needle biopsy because of something found on the MRI.
- About 10 additional cancers will be found even after ultrasound and mammography.
Molecular Breast Imaging (MBI) involves an injection of a radiotracer into your vein. About 5 minutes after the injection, each breast is placed between two detectors, similar to a mammogram but with less pressure. The test takes at least 40 minutes.
If 1,000 women have MBI:
- About 30 will be recommended to have a needle biopsy because of something found on MBI.
- About 7 cancers will be found that were not seen on the mammogram.
Contrast-enhanced mammogram (CEM) requires an injection of iodine-based contrast into your vein. This is the same contrast used in CT scans. It makes you feel warm all over and you may even feel like you might pee on yourself. After about 2½ minutes, you will have a CEM. The test takes about 10 minutes.
If 1,000 women have CEM:
- 30-50 women will be recommended to have a needle biopsy because of something found on the CEM.
- About 10 additional cancers will be found that were not seen on their mammograms.
Berg WA, Rafferty EA, Friedewald SM, Hruska CB, Rahbar H. Screening Algorithms in Dense Breasts: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 216:275-294
For more details about breast screening tests, visit our Technology Tab.
2. Does insurance cover my mammogram and any additional tests?
- In the U.S.A, under the Affordable Care Act (Obamacare), insurance carriers are required to cover the full cost of a screening mammogram. A screening mammogram is for women with no symptoms. If the screening is performed by 3D/tomosynthesis mammography, the full cost might not be covered by some insurance companies. It depends on the state in which you live (click here to learn more) and what insurance you have.
- Insurance coverage for additional screening tests after your mammogram, such as Ultrasound or MRI, varies by state and by insurance company. You should check with your insurance carrier(s) to learn if and how additional tests will be covered.
- For women at high risk for breast cancer, most insurers will cover a screening MRI (regardless of density), though a deductible/co-pay may apply, and pre-authorization may be needed.
- A diagnostic mammogram is for women with a sign or symptom of breast cancer, such as a lump or nipple discharge. A diagnostic mammogram is also used if additional mammography views are needed to clear up a question raised on a screening mammogram. A deductible/co-pay will usually apply for a diagnostic mammogram. But again, it depends on where you live and your insurance plan.
In Europe, national breast screening programs for women of average risk are offered in nearly all countries. Variations do exist on the ages and risk factors of women invited to participate in routine screening, how often screening is recommended, and supplemental screening tools used. For specific information by European country, click here.
3. What are insurance billing codes for additional breast screening tests?
- In the U.S.A., medical procedures are billed using both an ICD (International Classification of Disease) code and a CPT (Current Procedural Terminology) code.
- Use those codes to check with your insurance company to learn if a specific test should be covered and what your out-of-pocket costs (copay, deductible, or coinsurance) may be.
- Coverage varies by state and specific insurance plan.
Insurance Billing Codes by Breast Imaging Test
ICD CODE: For women with dense breasts, an appropriate ICD-10 code is 92.2 (which is “inconclusive mammogram” and can be used because of dense breast tissue). Note: other diagnosis codes may also apply based on medical history.
Terms you may hear: one breast = unilateral, both breasts = bilateral
|2D Mammogram (screening)||77067 (both breasts, 2-views of each)||Code also includes computer-aided detection (CAD) when performed.
The Affordable Care Act requires insurers to cover annual screening mammography beginning at age 40, without any out-of-pocket costs.
For younger women at high risk, screening mammography typically requires a prescription from a physician and may be subject to out-of-pocket costs.
|2D Mammogram (diagnostic)||77065 (one breast)|
77066 (both breasts)
|Codes also include computer-aided detection (CAD) when performed.
Diagnostic mammography is typically subject to out-of-pocket costs.
A diagnostic mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual mammogram performed as a diagnostic or a screening examination.
|3D Mammogram/tomosynthesis (screening)||77067 (2D both breasts) + 77063 (3D both breasts )||Most major insurers cover screening tomosynthesis; additionally, many states now require coverage. Out-of-pocket costs are possible.|
|3D Mammogram/tomosynthesis (diagnostic)||77065 (2D one breast) + 77061 (3D one breast)|
77066 (2D both breasts) + 77062 (3D both breasts)
G0279 – 3D (one or both breasts) if Medicare is primary insurance
|Out-of-pocket costs usual.
A diagnostic 3D mammogram is monitored by the radiologist and should only be performed for patients with an appropriate indication such as a lump, nipple discharge, other symptom, or to further evaluate or follow-up abnormalities previously noted on breast imaging. Women with a personal history of cancer can have their routine annual 3D mammogram performed as a diagnostic or a screening examination.
|Contrast-enhanced Mammogram (CEM)||Currently no CPT code|| Most CEM is done as part of research studies at this time.
In centers offering clinical CEM, billing is often under CPT code 77065 (one breast) or 77066 (both breasts). Out-of-pocket costs usual.
Some centers will also bill for the contrast and the contrast injection.
|Ultrasound||76641 (per breast)||“Complete” breast ultrasound is used for screening and will be billed for each breast, usually at half the rate for the second breast. Out-of-pocket costs usual in most states.
A “limited” breast ultrasound, 76642, is used to evaluate abnormalities or particular areas of concern.
|Molecular Breast Imaging, MBI||78800||Out-of-pocket costs usual.|
|Magnetic Resonance Imaging, MRI (with contrast)||77048 (one breast)|
77049 (both breasts)
|May require pre-authorization from your health provider. Out-of-pocket costs usual in most states.|
|Abbreviated MRI (with contrast)||Currently no CPT code unique to abbreviated MRI.||Many centers will bill directly to the patient (range $200-$600). The American College of Radiology endorses use of the modifier, “-52” (limited) exam, in combination with full protocol MRI CPT code 77049 (click HERE for more details, page 12).
Updated Nov 3, 2021. DenseBreast-info.org endeavors to provide up-to-date insurance codes; however, codes can change. These codes may not be the most recent version. No representations or warranties of any kind are made, express or implied, about the completeness, accuracy or reliability of this information provided. A patient should always check with their specific insurance provider.
4. If I have a 3D/tomosynthesis mammogram, do I also need a screening Ultrasound or MRI?
It is still important to have your mammogram first, as mammograms sometimes show some cancers that Ultrasound or MRI may not. The combination of tests finds the most cancers.
1. Tagliafico AS, Mariscotti G, Valdora F, et al. A prospective comparative trial of adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts (ASTOUND-2). Eur J Cancer 2018; 104:39-46
2. Destounis S, Arieno A, Morgan R. Comparison of cancers detected by screening ultrasound and digital breast tomosynthesis. Abstract 3162. In: American Roentgen Ray Society (ARRS). New Orleans, LA, 2017
3. Tagliafico AS, Calabrese M, Mariscotti G, et al. Adjunct screening with tomosynthesis or ultrasound in mammography-negative dense breasts (ASTOUND): Interim report of a prospective comparative trial. J Clin Oncol 2016
4. Dibble EH, Singer TM, Jimoh N, Baird GL, Lourenco AP. Dense breast ultrasound screening after digital mammography versus after digital breast tomosynthesis. AJR Am J Roentgenol 2019; 213:1397-1402
5. Comstock CE, Gatsonis C, Newstead GM, et al. Comparison of abbreviated breast MRI vs digital breast tomosynthesis for breast cancer detection among women with dense breasts undergoing screening. Jama 2020; 323:746-756
5. If I have dense breasts, should my routine annual mammogram be scheduled as a “screening” or a “diagnostic” mammogram?
A “screening” mammogram. Screening mammograms are for women with no signs or symptoms of breast cancer, whether or not they have dense breasts, family history of breast cancer, or other risk factors. In the U.S.A., screening mammograms are fully covered by insurance under the Affordable Care Act for women over the age of 40. They may also be covered for younger women if recommended by their physician and depending on their health insurance policy.
“Diagnostic” mammograms are used when there are signs and symptoms of breast cancer such as a lump, bloody or clear nipple discharge (not milk from breast feeding) or pulling in of the skin or nipple (called retraction). Diagnostic mammograms are also used to look at areas seen on earlier mammograms (like a screening mammogram) that need more pictures or closer follow-up. “Diagnostic” mammograms start with the same images as screening but are reviewed by the radiologist at the time of the mammogram and while the patient is there. A diagnostic mammogram is usually covered by insurance but out-of-pocket costs like a deductible and copay may be required.
6. If I am recommended to have more tests after my mammogram (like Ultrasound or MRI), will I need to have that every year?
Maybe. You should discuss this with your health care provider or Breast Imaging Radiologist. As you get older, your personal risk factors and how you might benefit from more screening after your mammogram may change. It is important to talk about your risk factors every year or two with your health care provider to determine what screening plan is best for you.
7. Is MBI or BSGI recommended for screening women with dense breasts?
Molecular Breast Imaging (MBI) and Breast Specific Gamma Imaging (BSGI) are breast imaging tests that use a small amount of radioactive material. These tests can find cancers hidden within dense breast tissue on a mammogram, but they are not usually recommended for breast cancer screening outside of research studies.
The radiation from MBI and BSGI is to the whole body, which is not like a mammogram, where only the breasts receive radiation (in a very small amount), and not like an Ultrasound or MRI, where there is no ionizing radiation at all.
MBI and BSGI are not used in women who are pregnant.
For more information about MBI, click here.
1. Rhodes DJ, Hruska CB, Conners AL, et al. JOURNAL CLUB: Molecular breast imaging at reduced radiation dose for supplemental screening in mammographically dense breasts. AJR Am J Roentgenol 2015; 204:241-251
8. Is thermography helpful in finding cancers in dense breasts?
No. Thermography is not an accurate test and is not recommended for screening. For additional information on thermography from the United States Food and Drug Administration, click here.