Does Medicare Cover Mammograms?


A 2D and 3D Mammogram Overview

A 3D mammogram, also known as digital breast tomosynthesis, is an imaging test that combines multiple breast X-rays to create a three-dimensional picture of the breast. It is used to look for breast cancer in men and women with no discernable signs or symptoms. This preventative procedure is also used to look at other breast problems such as a suspicious lump, thickening, pain, and nipple discharge.

When used as part of a breast cancer screening, 3D and standard 2D mammogram images are created. Combining these two types of mammograms reduces the need for additional imaging and slightly increases the number of cancers detected during screening.

Breasts are composed of dense milk glands, milk ducts, supportive tissue, and fatty tissue. Both dense breast tissue and cancers appear white on a standard mammogram, making breast cancer more difficult to detect in dense breasts and why a 3D mammogram can be more effective.

About half of all women have extra dense breast tissue detected only through radiology, not something that can be felt. Having dense breasts can make it harder for a radiologist to see small changes related to cancer, and unfortunately, women with dense breast tissue are at higher risk for breast cancer.

Although mammogram screenings are safe, there are some small risks to consider. Patients are exposed to a low level of radiation, and false positives can appear when an abnormality turns up but is not cancer. The tests can miss some areas of cancer, such as if the cancer is very small or in an area that's difficult to see.

Results are synthesized by computer and interpreted by a radiologist. If abnormalities are detected, a patient may be advised to undergo an ultrasound, an MRI, or a biopsy for pathology testing.


Breast Cancer Screenings in Men

Cancer screening tests take place for men before you have any symptoms or signs. A doctor may recommend breast screenings for men if they have a genetic mutation (such as BRCA genes) that increases their breast cancer risk.

They may also have a condition like Klinefelter syndrome that predisposes them to cancer. Other risk factors include estrogen therapy, injury or removal of the testicles, liver cirrhosis, family history of cancer, or a history of radiation to the chest to treat another cancer.

Mammograms are the preferred imaging test, but many men do not have enough breast tissue to have the test, so an ultrasound is a preferred alternative


What Medicare Covers

Medicare coverage pays for 2D and 3D mammography screenings. No physician's prescription or referral is required for this preventative care. There are some conditions:

  • Medicare pays for a screening 3D (Tomosynthesis) mammogram with no out-of-pocket expense for patients.
  • Medicare does not pay for screening mammograms for female beneficiaries younger than 35.
  • Medicare will pay for one baseline mammogram for female beneficiaries between 35 and 39.
  • Medicare covers annual screening mammography for women 40 and over once per calendar year. After a woman reaches 40, a screening mammogram has to have occurred at least 11 months after the last covered screening mammogram.

For women on Medicare, screening mammograms are free as long as their doctor agrees to charge no more than what Medicare recommends. Mammogram coverage is also provided for men at high risk or for anyone who has symptoms.

Transgender individuals are also covered if the mammogram is considered medically appropriate based on their situation.

It's essential to understand the difference between screening mammograms and diagnostic mammograms. Screening mammograms look for cancer in people who do not have symptoms. Diagnostic mammograms are for people who have symptoms. Although screening mammograms are free, you will pay 20% for a diagnostic mammogram unless you have a Medicare Supplemental plan. The average out-of-pocket cost of a diagnostic mammogram with Medicare is around $170.

Medicare covers 3D breast MRIs if necessary. You can also expect to pay a Part B deductible 20% of the cost of an MRI if you don't have Medicare supplement insurance.

According to Medicare, talk to your doctor or health care provider to find out exactly how much your test, item, or service will cost. The specific amount of copayments and coinsurance you'll owe may depend on several things:

  • Other insurance you may have
  • How much your doctor charges
  • If your doctor accepts assignment
  • The type of facility
  • Where you get your test, item, or service

Also, your health care provider may recommend you get services more often than Medicare covers or recommend services that Medicare doesn't cover. You may have to pay some or all the costs if this happens.

DISCLAIMER:  Medi-Solutions Insurance Agency, LLC is not affiliated or endorsed with the Social Security Administration or the Federal Medicare Program. Information is for educational purposes only and should not be construed as an offer of insurance, advice, or recommendation. The information provided is not intended as tax, financial, investment, or legal advice. Please consult legal or tax professionals for specific information regarding your situation.

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