Table of ContentsView AllTable of ContentsBreast MRIGuidelinesMedicare CoverageCostOptions if Denied
Table of ContentsView All
View All
Table of Contents
Breast MRI
Guidelines
Medicare Coverage
Cost
Options if Denied
Although breast MRI is more expensive, studies have shown it may be more likely to detect cancer than other tests.However, certain criteria must be met to qualify for Medicare coverage and some costs may be your responsibility.
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How Breast MRI Works
Breast magnetic resonance imaging (MRI)uses magnetic fields and radio waves to take a picture of the breast. There are no X-rays involved.
A contrast dye is injected into a vein to make areas with increased blood flow stand out more in the images. This is important because cancerous tumors tend to form new blood vessels around them that help them grow.
It was once thought that breast MRI had to be performed early in the menstrual cycle for premenopausal people. The belief was that hormonal changes affected blood flow in the breast that could decrease the test’s sensitivity.
However, newer studies have shown that is not the case. Breast MRI can be performed at any time, making scheduling much easier for many people.
Keep in mind that anyone with a previous reaction to contrast dye or who has underlying kidney disease should talk to their healthcare provider before getting the test.
What Are Sensitivity and Specificity?Sensitivity and specificity are measures of a test’s accuracy. Sensitivity is a test’s ability to identify the presence of a disease in someone who actually has the disease, known as the true positive rate. The higher a test’s sensitivity, the more likely a positive test result means someone truly has the condition.On the other hand, specificity is the test’s ability to correctly identify the absence of a disease, known as the true negative rate. Higher specificity means that a normal test is less likely to have missed something.
What Are Sensitivity and Specificity?
Sensitivity and specificity are measures of a test’s accuracy. Sensitivity is a test’s ability to identify the presence of a disease in someone who actually has the disease, known as the true positive rate. The higher a test’s sensitivity, the more likely a positive test result means someone truly has the condition.On the other hand, specificity is the test’s ability to correctly identify the absence of a disease, known as the true negative rate. Higher specificity means that a normal test is less likely to have missed something.
Sensitivity and specificity are measures of a test’s accuracy. Sensitivity is a test’s ability to identify the presence of a disease in someone who actually has the disease, known as the true positive rate. The higher a test’s sensitivity, the more likely a positive test result means someone truly has the condition.
On the other hand, specificity is the test’s ability to correctly identify the absence of a disease, known as the true negative rate. Higher specificity means that a normal test is less likely to have missed something.
High-Risk MRI Assessment Guidelines
When it comes to testing, MRI may be recommended for people who:
For people with a breast cancer diagnosis, detailed imaging may help in making treatment decisions.
MRI is more sensitive than a mammogram and breast ultrasound when used to screen females at a 20% or higher lifetime risk for breast cancer. The National Cancer Institute (NCI) offers a straightforward online tool to check your risk. It’s called theBreast Cancer Risk Assessment Tool.
The sensitivity for MRI in this population was 90%, but only 37.5% for mammograms or ultrasound.MRI also outperformed mammograms and ultrasound even when they were used together.
Below are some factors that can increase the risk of breast cancer in females.
Age
The risk for breast cancer increases as you get older. According to the American Cancer Society, 129 out of every 100,000 females are diagnosed with breast cancer every year.Between 2015 and 2019, the median age at breast cancer diagnosis was 62.
Recommended Age for Breast Cancer ScreeningThe U.S. Preventive Services Task Force (USPSTF) recommends breast cancer screening with a mammogram every two years for females between 40 and 74 years old.
Recommended Age for Breast Cancer Screening
The U.S. Preventive Services Task Force (USPSTF) recommends breast cancer screening with a mammogram every two years for females between 40 and 74 years old.
Diethylstilbestrol Exposure
The drugdiethylstilbestrol(DES) was used to treat pregnancy-related complications from 1938 to 1971. The drug is no longer given to pregnant people because it was found to increase the rate of cancer and other health conditions in women who took the medication and also in children who were exposed to DES during pregnancy.
Studies have shown that people who took DES during pregnancy had a 30% higher risk for breast cancer than other women. Their female children were also at increased risk for:
Family History and Genetics
Certain people may be at increased risk for breast cancer based on:
Females with a BRCA-1 gene mutation have a 72% lifetime risk of developing breast cancer, and those with the BRCA-2 gene mutation have a 69% risk. These genes also increase ovarian cancer risk.
Medical Findings on Mammogram
A questionable finding on a mammogram may require further evaluation. If a radiologist is uncertain about something they see on a mammogram, they may recommend another kind of imaging study, like a breast MRI, to take a closer look. In some cases, they may recommend a biopsy (tissue removal to analyze in the lab) instead.
Some people with a history of breast cancer may have had surgery orradiationthat can leave scar tissue in the area. Radiation to the chest of any kind (such as for Hodgkin’s lymphoma) may make a mammogram harder to interpret.
Radiation exposure itself could also increase the risk of cancer in the area. MRI is the best tool to differentiate between scar tissue and possible recurrent cancer.
Dense BreastsNearly half of females have dense breasts, as detected on their mammograms. This tissue appears whiter on mammograms, making it harder for a radiologist to find small cancers. Although women with dense breast tissue are at higher risk for breast cancer, breast MRI generally is not recommended for people in this group.Breast ultrasoundtends to be the preferred next step. When used with a mammogram, sensitivity is as high as 96%.
Dense Breasts
Nearly half of females have dense breasts, as detected on their mammograms. This tissue appears whiter on mammograms, making it harder for a radiologist to find small cancers. Although women with dense breast tissue are at higher risk for breast cancer, breast MRI generally is not recommended for people in this group.Breast ultrasoundtends to be the preferred next step. When used with a mammogram, sensitivity is as high as 96%.
Nearly half of females have dense breasts, as detected on their mammograms. This tissue appears whiter on mammograms, making it harder for a radiologist to find small cancers. Although women with dense breast tissue are at higher risk for breast cancer, breast MRI generally is not recommended for people in this group.
Breast ultrasoundtends to be the preferred next step. When used with a mammogram, sensitivity is as high as 96%.
Personal History of Breast Cancer
A past history of breast cancer in one breast, whether it was localized or at an advanced stage, increases the risk of developing breast cancer in the other breast.However, this statistic has been improving with advancements in breast cancer treatment.
A 2021 report found the five-year cumulative incidence of developing cancer in the other breast was from 1% to 2% in those diagnosed with first breast cancer from 2004 to 2016.
Race and Ethnicity
Breast canceris the most common type of cancer in females of all races and ethnicities, affecting 1 in 8 females in their lifetime. However, Black women are more likely to present with advanced disease at the time of their diagnosis. They also historically have had a higher mortality rate than White women.
Black women also represent a higher percentage of women diagnosed with triple-negative breast cancer before 40 years old.This type of breast cancer is aggressive and has more limited treatment options.
Reproductive History
The more estrogen a female has been exposed to in their lifetime increases breast cancer risk. People who had menarche (their first menstrual cycle) before age 12 and/or hadmenopause(the end of their menstrual cycles) after age 55 have increased rates of breast cancer.
During pregnancy, people are not exposed to as much estrogen because their menstrual cycles are paused. For this reason, females who have never had children and, therefore, have had more estrogen exposure tend to have higher rates of breast cancer than people who have had a full-term pregnancy.
That said, people who have a first full-term pregnancy after age 30 have a higher breast cancer rate than females who have never been pregnant.This suggests that pregnancies earlier in life may be somewhat protective against breast cancer later in life.
Modifiable Risk Factors
The risk factors described previously are out of your control. The following are modifiable risk factors you can change:
Breast Implants
Breast implants, whether they are saline or silicone, have not been associated with an increased risk for breast cancer.However, there are instances when a person who hassilicone breast implantsmay benefit from a breast MRI. Compared to ultrasound or mammogram, MRI has the highest sensitivity and specificity for ruptured silicone implants.
Diagnosing breast cancer
The only definitive way to diagnose breast cancer is with a biopsy (breast tissue sample).
Medicare Coverage for Breast MRI
Medicare does not cover breast MRI for everyone. To qualify for coverage, certain criteria must be met.
Beneficiary Eligibility
LCD guidelines from December 2023 limit breast MRI to the following types of cases:
Other Types of Covered Breast Screening
If you’re under 65 and receive disability benefits from Social Security, you get Medicare automatically after getting disability benefits for 24 months.In this case, Medicare covers one baseline mammogram for women 35–39 years old and annual mammograms for women 40 years and older. There is no age cap.
To be clear, Medicare specifically limits screening to women. Transgender individuals may also be covered if a screening mammogram is considered medically appropriate based on their biology and whether they have undergone hormonal or surgical procedures.
Diagnostic mammograms may be performed more often than every 12 months if your healthcare provider considers them medically necessary. These tests can be ordered for anyone who has an abnormal mammogram finding, a prior history of breast cancer, or symptoms related to the breasts.
Breast ultrasound is a diagnostic test and is not considered preventive screening according to Medicare. Again, someone may qualify for Medicare coverage for breast ultrasound if it is deemed medically necessary, such as in these cases:
Screening vs. Diagnostic TestsPreventive screening tests are intended to detect disease before symptoms develop. A diagnostic test is performed when someone has symptoms or in follow-up to abnormal findings.
Screening vs. Diagnostic Tests
Preventive screening tests are intended to detect disease before symptoms develop. A diagnostic test is performed when someone has symptoms or in follow-up to abnormal findings.
Cost Factors
Breast MRI is one of the more expensive imaging procedures for cancer screening. That is one of the reasons many health plans, including Medicare, limit coverage for its use.
The out-of-pocket cost for breast MRI will vary based on where you live. According toFAIR Health Consumer, a free database of healthcare costs, an MRI of both breasts on average costs $644 in New York, $626 in Chicago, and $1,510 in Los Angeles.
Keep in mind these rates represent the cost you would pay without insurance. The cost would be higher if a biopsy were performed at the same time.
Medicare Specifics: Parts A–D
Medicare is a federally funded health insurance program for adults over 65 and people withqualifying disabilitiesregardless of age. It is divided into four parts:
Saving With Medigap
They help pay down costs that Medicare leaves on the table, including your co-pays, coinsurance, and deductibles (not your premiums). Depending on the Medigap plan you choose, they can pay your Part A hospital costs and 20% Part B coinsurance.
What to Do if Coverage Is Denied
Not every test will be approved for coverage. Medicare could argue that a breast MRI is not medically necessary for your situation. If your healthcare provider feels that the test is needed, you may choose to seek an appeal. A letter from your healthcare provider and additional documentation may support your request.
The Medicare appeals process can be time-consuming, but unless you are willing to seek alternative financing or pay out of pocket, you may have limited options.
You may consider reaching out to the following organizations for assistance in finding affordable breast cancer screening and for making a case for an appeal:
Summary
Mammograms are an effective screening tool, but they are not always accurate in females with a high risk for breast cancer. This may include females with BRCA gene mutations, certain medical conditions, and a history of cancer that was treated with surgery or radiation. In those cases, breast MRI may be better able to detect small cancers.
It is also a helpful tool in investigating abnormalities found on a mammogram or in planning for treatment in people of any sex or gender who have already been diagnosed with breast cancer.
Medicare coverage of breast MRI is limited, and certain criteria must be met. Your healthcare provider may need to provide documentation to Medicare to show that you need the test.
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