Medicare Refusing to Pay for Cancer Scan Sparks Warning for Patients

Women who are on Medicare are being warned that their government-provided healthcare might not cover all the services they need at their next OB-GYN appointment.

When it comes to breast cancer screening, women are often told they need an additional scan beyond just a mammogram because these scans can miss tumors in women with dense breast tissue. However, Medicare has routinely refused to cover the lifesaving ultrasound and MRI scans that the doctors order, The New York Times reported last week.

New York City’s Lenox Hill Radiology has already started sending out warnings to patients, telling them they will be forced to pay up to $450 if they do end up getting the extra scans.

While Medicare’s official policy covers breast ultrasounds in some situations, it’s limited “to assess palpable or nonpalpable breast masses, ambiguous mammograms and other signs or symptoms suggestive of breast cancer.” That specific rule is vague enough that many women reported being on the hook for the hefty $450 cost despite it being included in their routine checkups.

Many of these patients who require additional scans have a family history of breast cancer and have needed extra scans all through adulthood.

“I just don’t understand how something that has been the recommended diagnostic test for years is suddenly not covered by Medicare,” Joellen Sommer, 66, told the Times. “My mother had breast cancer, my aunt had breast cancer—I guess that’s not enough. I wonder if it was a test for men, if the same issue would arise.”

Roughly one in eight women will end up having breast cancer in her lifetime, making it the most common cancer in women.

“Medicare does not require a copay for a screening mammography,” a spokesperson for Centers for Medicare & Medicaid Services (CMS) told Newsweek via email on Friday morning. “Because an ultrasound, such as the automated breast ultrasound, is not a radiologic procedure, it cannot be considered a ‘screening mammography’ modality for the purpose of Medicare coverage.”

The spokesperson said Medicare may cover breast ultrasound tests when “reasonable” and “necessary” for the diagnosis based on the Social Security Act, or if a clinician determines it is medically necessary.

“In the case of a diagnostic test, including the automated breast ultrasound, Medicare pays 80 percent of the reasonable charges for diagnostic ultrasound services, while the Medicare beneficiary pays 20 percent,” the spokesperson added.

Since the Affordable Care Act was passed by former President Barack Obama, more women have had their breast cancer found in early stages rather than when it’s too late. This is because Medicare has offered free mammograms, but extra charges often apply if the doctor thinks another scan is needed.

The issue is widespread, as around half of women aged 40 and older who get mammograms have dense breast tissue and may end up needing an additional scan to detect for cancer, according to the National Cancer Institute (NCI).

The warning comes as all mammography centers in the United States are going to be required to tell patients if they have dense breasts beginning in September. Those with dense breast tissue who only get mammograms could miss about half of the cancers present, doctors say.

Lawmakers have also gotten on board in support of requiring health insurance plans to cover screening and diagnostic breast imaging, which includes mammograms, ultrasounds and MRIs. Representative Rosa DeLauro, a Connecticut Democrat, and Representative Brian Fitzpatrick, a Pennsylvania Republican, proposed the Find It Early Act to promote this effort.

So far, the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF) do not recommend extra breast cancer scans for those with dense breast tissue, but doctors routinely find it necessary when working with patients.