Will insurance cover supplemental screening beyond mammography?

In the U.S., the answer depends on the type of screening, patient’s insurance, risk factors, the state you practice in, and whether or not a law is in effect requiring insurance coverage for additional screening. In Illinois, for example, if ordered by a physician, a woman with dense breasts can receive an ultrasound without a copay or deductible. In New York as of January 1, 2017 all supplemental screening and diagnostic breast imaging are required to be fully covered (no copay/no deductible), though exceptions do exist. Generally, in other states, an ultrasound will be covered if ordered by a physician – but is subject to the copay and deductible of an individual health plan. In New Jersey, insurance coverage is provided for additional testing if a woman has extremely dense breasts. An MRI will generally be covered if the patient meets “high-risk” criteria*. In Michigan, at least one insurance company will cover a screening MRI for normal-risk women with dense breasts at a cost which matches the copay and deductible of a screening mammogram (which in most cases is zero). It is important for the patient to check with her insurance carrier prior to having an MRI. For insurance billing codes for additional breast screening, click here.

In Europe, national breast screening programs for women of average risk are offered free in nearly all European countries adhering to standards laid out in the European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis. Variations do exist on the ages and risk factors of women invited to participate in routine screening, screening intervals, coverage and supplemental screening modalities utilized. Opportunistic mammography exists in some countries either as the sole screening system or in addition to the national breast screening program. Part of the cost is out of pocket payment or reimbursed by private insurance.

*For more information on high-risk criteria, see American Cancer Society guidelines: https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html