Healthcare payment policy in the United States is complicated, and nowhere is this more apparent than for preventive services. Coverage differs among payers, including traditional Medicare, Medicare Advantage, Medicaid and commercial insurance. In addition, the process to obtain reimbursement for new services and procedures varies, creating challenges and confusion for patients and physicians alike.
When Congress created Medicare under Title XVIII of the 1965 Social Security Act, only diagnostic services and treatments for illnesses were included. Amendments to the original statute were necessary to provide Medicare coverage for preventive services. Screening mammography, for example, was not covered by Medicare until the Omnibus Reconciliation Act of 1990.
In 2008, Congress passed the Medicare Improvements for Patients and Providers Act (MIPPA), which granted the authority to expand coverage for screening to the secretary of Health and Human Services (HHS) through the national coverage determination (NCD) process. To qualify under Medicare coverage, a preventive service must be determined by the HHS secretary to be “reasonable and necessary for the prevention or early detection of an illness or disability; recommended with a grade A or B by the USPSTF [U.S. Preventive Services Task Force]; and appropriate for individuals entitled to benefits under Medicare.”1
Of note, MIPPA does not require coverage based solely on USPSTF recommendation. In addition to the HHS secretary, the Centers for Medicare and Medicaid Services (CMS) can also establish Medicare coverage for preventive services following similar guidelines.
Although Medicare is a federal program, Medicare claims are processed through a network of private healthcare insurers called Medicare Administrative Contractors (MACs) in different geographic regions.2 For most services, absent an NCD, coverage for new procedures can also be obtained through a local coverage determination (LCD). The MACs develop LCDs for their regions with input from carrier advisory committees for each state.3 Nonetheless, pursuant to Section 1861 (ddd) of the Social Security Act, coverage for screening and preventive services requires an NCD.4
Under the Affordable Care Act (ACA) enacted in 2010, coverage for screening services by commercial health insurance plans and state Medicaid expansion programs (but not Medicare) is governed by the USPSTF and the Health Resources Services Administration. Only screening tests that receive a grade A or B recommendation from the USPSTF are covered without out-of-pocket expense for beneficiaries. At the current time, Congress has delayed until Jan. 1, 2024, coverage based on the 2016 USPSTF screening mammography guidelines, which call for biennial screening mammograms between ages 50 and 74. Additionally, in December 2022, the Find It Early Act was introduced in Congress to ensure all health insurance plans, including Medicare, cover screening and diagnostic mammograms, breast ultrasounds and MRIs without cost sharing.5
Currently, there are no USPSTF guidelines for supplemental screening in patients with dense breast tissue and/or those at increased risk for breast cancer due to genetic mutations, family history and other risk factors. Many states have passed legislation mandating patient notification of breast density. Some states also require coverage for supplemental screening tests, such as whole-breast ultrasound or breast MRI.
While these payment mandates can apply to commercial payers and state Medicaid programs, Medicare is a federal program with coverage determined at the national level. In addition, while screening services with a USPSTF A or B recommendation must be covered without out-of-pocket expense under the ACA, this requirement does not apply to other diagnostic studies. Even diagnostic mammograms and breast ultrasound in patients recalled for additional evaluation after screening mammography may be subject to co-pays and deductibles.
Lack of coverage is sometimes mistakenly attributed to the absence of a Current Procedural Terminology (CPT®) code. While CPT codes are necessary for Medicare billing, they do not mandate coverage — with or without cost sharing by patients — for screening services without an NCD.
Even if there is a CPT code that could be used for a screening test — for example, code 76641 for complete breast ultrasound or code 77049 for bilateral breast MRI without and with contrast — Medicare will not cover these exams for a screening indication without an NCD, regardless of how the codes were designed and approved through the CPT and Relative Value Scale Update Committee process.
Ultimately, because coverage guidelines vary from payer to payer and can change over time, physicians and patients are strongly encouraged to check with the payers in their markets.