A Model Legislation for Women: Coverage and Payment of 3D Mammography

On June 1, 2018, House Bill number 1252 was passed in Missouri, bringing great promise for female patients all over the country. The new law requires coverage and payment of 3D mammography (also known as Tomosynthesis) beginning on January 1, 2019 and includes the following:

  • A mammogram every year for women age forty or over
  • A mammogram for every woman, upon the recommendation of a physician, here such woman, her mother or sister has a prior history of breast cancer 
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The state of Texas, Arkansas, Illinois, Kentucky, Maryland, New Jersey, and Pennsylvania have all passed State Legislation regarding the coverage of 3D mammography. This is not only big news in terms of cost-savings for patients, it’s also beneficial for their health and safety.

3D mammography is an FDA-approved technology that allows radiologists to view a three-dimensional picture of a breast, as opposed to the traditional 2D version which obtains just a single image from the front and side. 3D converts the digital images into “slices,” or very thin layers 1-millimeter thick which produces details that may be hidden in a 2D image. The advanced imaging allows doctors to view clearer images of breast masses, and practices have seen a large reduction in false positives. The biggest advantage is that 3D mammography detects breast cancer at an earlier stage, meaning that it highly demonstrates an improvement in patient survival. The possibility for this law to be more widely accepted is exciting, but the real question is, will the rest of the country follow suit?

The pressure falls on providers and majorly insurers. For many years, most refused to pay for a patient’s 3D mammogram for a myriad of reasons. The technology was either too new, “unproven,” or deemed not medically necessary. However, with notable evidence in favor of 3D mammography compared to 2D, it’s time for both parties to step up and begin providing coverage for patients.

There's good news for providers reporting under the Medicare Access and CHIP Reauthorization Act (MACRA). Providing the best care possible, which could include reporting on providing and covering 3D mammography, could mean improved participation under the Merit-Based Incentive Payment System (MIPS). Before doing so, providers must ensure that those codes fall under the correct reporting measures.

In the mean time, what should women do who don’t know if they’re covered? Talk to your doctor about which type of mammogram is right for you, contact your insurance carrier with questions about the benefits you’re entitled to under state law, and ask ahead of time if you’re expected to pay any out-of-pocket expenses for a mammogram.

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