The New York Times has published an article highlighting the Medicare and other payor payment policies that limit coverage of breast imaging tests performed for asymptomatic women other than screening mammograms. Concerns are being raised particularly over the lack of coverage for additional breast imaging services for these asymptomatic women who are found to have dense breasts.

This came when the US Food & Drug Administration (FDA) made major changes to its mammography quality standards regulations (which will become effective in September 2024) which will require that the mammography reports sent to patients written in lay language contain information about their breast density. Advocates contend that a screening mammogram - by itself - may not adequately reveal all abnormalities for women with dense breasts. Screening mammography patients aged 40 to 74 can self-refer themselves for screening mammograms which are made available without out-of-pocket costs. Mammography facilities may perform follow-up covered diagnostic breast imaging studies -- including diagnostic mammograms, breast ultrasound scans, and breast MRI --  if they are ordered by the patient's treating physician as clinically indicated based on the radiologist's mammographic findings that are equivocal, or if they are suspicious or suggestive of malignancy. In that circumstance, these additional tests are covered but carry out-of-pocket cost to the patient. They are not covered if performed for asymptomatic women.

Legislation introduced last year in the U.S. Congress, The Find it Early Act, would require all private payers - along with traditional Medicare and Medicare Advantage plans, Medicaid and TRICARE - to cover any supplemental breast imaging services, beyond screening mammograms ordered by the patient's physician. These appropriately ordered supplemental imaging exams would be available to women with no patient out-of-pocket costs for co-payment and deductible payments.

To be clear, coverage exists for follow-up diagnostic breast imaging studies. Coverage exists, for example, when radiologists perform diagnostic mammograms based on the findings of the screening study -- or when a diagnostic mammogram is performed instead of a screening study based on the symptomatic status of the patient. Coverage is also available for diagnostic mammograms, breast ultrasounds, and breast MRI studies when the patient's treating physician determines that such studies are medically indicated.  Such studies nevertheless place payment responsibility upon patients for co-payment and deductible amounts. 

Moreover, no coverage exists for screening breast ultrasound studies or breast MRI exams for patients with dense breasts. Some researchers contend that mammography plus breast ultrasound was better than even an AI-assisted mammogram at finding cancer in patients with dense breasts.  And in 2022 the European Society of Breast Imaging recommended offering screening breast MRI studies every 2–4 years in women aged 50–70 years with extremely dense breasts. 

Addressing the possibility of coverage and the payment for these important women's imaging studies is a critical policy issue that is worthy of careful deliberation by Congress, state legislatures, and CMS.  At a time when preventive health service coverage is under attack in the courts, one hopes that Congress will step in to support and expand important breast cancer testing services with coverage by Medicare and all payors.