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Monday, May 27, 2024

Medicare Coverage Gap Leaves Some Women with Dense Breast Tissue Facing Screening Costs

As women seek routine breast cancer screenings, many with dense breast tissue encounter an unexpected hurdle: Medicare coverage gaps for supplemental scans, such as ultrasounds or M.R.I.s., which are often deemed necessary for early cancer detection in this population.

Joellen Sommer, 66, found herself in this predicament during her annual breast cancer screening. While Medicare covered her mammogram, the supplemental ultrasound, crucial for detecting tumors in dense breast tissue, was not included. Despite dense breasts and a family history of breast cancer, she was left baffled by the sudden denial of coverage.

Similarly, Lenox Hill Radiology in New York City began cautioning Medicare-insured patients about potential out-of-pocket costs for breast ultrasounds, leaving them potentially liable for up to $450, even when performed alongside a mammogram on the same day.

The discrepancy arises from Medicare’s limited coverage of breast ultrasound, which is only reimbursed under specific circumstances, such as assessing breast masses or ambiguous mammograms. This leaves women like Ms. Sommer grappling with unexpected expenses for what they perceive as routine preventive care.

Dense breast tissue poses a challenge for mammograms, as both tumors and dense tissue appear white on X-rays, making early cancer detection difficult. Nearly half of women aged 40 and older undergoing mammograms have dense breast tissue, underscoring the prevalence of this issue.

To address this, starting in September, all mammography centers in the U.S. will be required to inform patients of their breast density. Advocates argue that mammograms alone are insufficient for women with dense breasts, as they miss approximately half of cancers present in such cases.

The Find It Early Act, proposed by Representatives Rosa DeLauro and Brian Fitzpatrick, seeks to rectify this by mandating insurance coverage for comprehensive breast imaging, including ultrasounds and M.R.I.s., with no cost sharing. However, the bill awaits approval, leaving many women in limbo.

While some advocate for alternative screening methods, such as 3-D mammography, others, like the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force, have not endorsed additional screening for patients with dense breasts due to insufficient clinical trial data.

Despite debates over the value of supplementary screening, advocates emphasize the urgency of detecting cancers early, especially in dense breast tissue, where tumors may go unnoticed on mammograms alone. False positives and the high costs associated with alternative scans remain concerns, but proponents argue that the potential benefits outweigh these drawbacks.

For now, women like Ms. Sommer are left navigating the complexities of insurance coverage and grappling with the financial burden of necessary but uncovered screening tests. As policymakers weigh the merits of expanded coverage, the need for accessible and comprehensive breast cancer screening remains a pressing issue for many.

Jonathan James
Jonathan James
I serve as a Senior Executive Journalist of The National Era
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