February 10, 2017

States Consider Mandated DBT Coverage

At least five states, identified by ACR’s Statescape State Legislative Roundup, are considering legislation that would require health care insurers to cover digital breast tomosynthesis (DBT).

Clinical research suggests DBT may be diagnostically superior to digital X-ray mammography, with higher cancer detection rates and fewer patient recalls for additional testing.

DBT could also reduce the cost of breast cancer diagnosis and clinical management. According to a study published online on Jan. 27 in the Journal of the American College of Radiology, digital breast tomosynthesis (DBT) in combination with full-field digital mammography (FFDM) could save average-sized state Medicaid programs more than $200,000 per year and save more than $12,000 per year for an average-sized individual Medicaid plans.

This is important evidence that tomosynthesis will have a positive impact on patient care. The American College of Radiology’s position on DBT is that it is no longer investigational and that it has been shown to improve key screening parameters compared to digital mammography.

Because of spotty insurance coverage, however, many patients incur additional co-payments when DBT is performed in combination with full-field digital mammography. The following state bills have been introduced to address the issue.

Maryland SB 61
Establishes that a specified coverage requirement that applies to specified insurers, nonprofit health service plans and health maintenance organizations includes coverage for digital tomosynthesis under specified circumstances; prohibits a copayment or coinsurance requirement that is greater than for other breast cancer screenings; applies the act to all policies, contracts and health benefit plans issued, delivered or renewed in Maryland on or after Jan. 1, 2018.

New Hampshire SB 189
Requires insurance policies to cover 3D mammography. Expands the definition of "low-dose mammography" to also include 3D tomosynthesis mammography.

New Jersey AB 4320
Mandates that health insurers provide coverage for digital tomosynthesis for screening and diagnostic purposes related to breast cancer. Requires health insurers and health maintenance organizations, as well as health benefits plans or contracts, to provide coverage for expenses incurred while conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over and for diagnostic purposes in women of any age.

New York SB 1709
Requires insurers to cover three-dimensional mammograms under mammography services and extends exclusion from annual deductibles and coinsurance to such services.

Texas HB 1036
Adds a definition of "breast tomosynthesis" and relates it to coverage for certain breast cancer screening procedures under certain health benefit plans.

In addition to Statescape, the ACR has created a DBT Resources Page to help its members work with private payers to secure coverage of this important technology.