Dana H. Smetherman, MD, MPH, MBA, FACR, American College of Radiology® Treasurer, and Radiology Department Chair and Associate Medical Director at Ochsner Medical Center in New Orleans, contributed this piece.
Recently, many radiologists became aware of the complexities of payment policy for screening and preventive services when Medicare Administrative Contractors began auditing practices performing breast ultrasound for screening. When Medicare was created in 1965, only diagnostic services and treatments for illnesses were included. Screening was not contemplated, likely because there were few effective ways to detect pre-clinical disease in the Medicare population at the time. To obtain Medicare coverage for screening services, amendments to the original statute, such as the Omnibus Reconciliation Act of 1990, which provided Medicare coverage for screening mammography, were necessary. In 2008, the Medicare Improvements for Patients and Providers Act gave the authority to expand coverage for screening to the Secretary of Health and Human Services through the National Coverage Determination (NCD) process. In addition, the Centers for Medicare and Medicaid Services can develop NCDs for Medicare coverage of screening and preventive services. Even with applicable Current Procedural Terminology (CPT) codes, such as 76641 for complete breast ultrasound and 77049 for bilateral breast MRI without and with contrast, Medicare will not cover an exam performed for a screening indication without an NCD.
Payment policy also varies among insurers. Coverage for screening services by commercial health insurance plans and state Medicaid expansion programs is governed by the United States Preventive Services Task Force (USPSTF) and the Health Resources Services Administration. Only screening tests with a grade A or B recommendation from the USPSTF are covered without out-of-pocket expense. For now, Congress has delayed adoption of the USPSTF guidelines for screening mammography, which only recommend biennial screening mammograms between ages 50 and 74, until Jan. 1, 2024. Also, there are no USPSTF guidelines for supplemental breast cancer screening in patients with dense breast tissue and/or those at increased risk due to genetic mutations, family history and other risk factors.
While some states have passed legislation requiring breast density notification, and even reimbursement for supplemental screening, these payment mandates only apply to commercial payers and state Medicaid programs. Because Medicare is a federal program, coverage for screening tests is determined at the national level. Still, there are avenues to advocate for coverage of supplemental screening tests for our patients. For example, in December 2022, the Find It Early Act bill was introduced in Congress. This proposed legislation would ensure all health insurance plans, including Medicare, cover screening and diagnostic mammograms, breast ultrasounds and MRIs without cost sharing.