Medicare coverage for a breast MRI is determined on a case by case basis.
There are no X-rays involved.
This is important because cancerous tumors tend to form new blood vessels around them that help them grow.
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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 tests 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.
What Are Sensitivity and Specificity?
Sensitivity and specificity are measures of a tests accuracy.
The higher a tests sensitivity, the more likely a positive test result means someone truly has the condition.
Higher specificity means that a normal test is less likely to have missed something.
The National Cancer Institute (NCI) offers a straightforward online tool to check your risk.
Its called theBreast Cancer Risk Assessment Tool.
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.
Diethylstilbestrol Exposure
The drugdiethylstilbestrol(DES) was used to treat pregnancy-related complications from 1938 to 1971.
These genes also increase ovarian cancer risk.
Medical Findings on Mammogram
A questionable finding on a mammogram may require further evaluation.
In some cases, they may recommend a biopsy (tissue removal to analyze in the lab) instead.
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 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.
Breast ultrasoundtends to be the preferred next step.
When used with a mammogram, sensitivity is as high as 96%.
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.
During pregnancy, people are not exposed to as much estrogen because their menstrual cycles are paused.
Modifiable Risk Factors
The risk factors described previously are out of your control.
Compared to ultrasound or mammogram, MRI has the highest sensitivity and specificity for ruptured silicone implants.
Not all abnormalities, however, will be cancerous.
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
Breast MRI has a local coverage determination (LCD).
Instead, decisions for coverage are made case by case.
There is no age cap.
To be clear, Medicare specifically limits screening to women.
Diagnostic mammograms may be performed more often than every 12 months if your healthcare provider considers them medically necessary.
Breast ultrasound is a diagnostic test and is not considered preventive screening according to Medicare.
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.
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.
These plans are regulated by the federal government but are run by private insurance companies.
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.
In those cases, breast MRI may be better able to detect small cancers.
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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