Mammograms are considered the gold standard for breast cancer screening, but they are not 100% accurate. In some cases, other imaging studies are needed to determine if a biopsy (removing a sample tissue for further examination) is necessary to check for cancer.
Medicare covers screening mammograms for free. But breast ultrasounds are also recommended for many women, especially those with dense breast tissue.
This article will explain when Medicare pays for breast ultrasound and how much it will cost.
Breast Cancer Screening
Breast cancer is the most common type of cancer in women, affecting one in eight women in their lifetime. Men also can get breast cancer; they account for one of every 100 cases.
The Affordable Care Act (Obamacare) changed how many women get screened for cancer. With more than 60 million people on Medicare and 18% of them having dual eligibility for Medicaid, free mammograms significantly impacted women of all ages.
The number of breast cancers found in the early stages has increased since the Affordable Care Act became law. Fewer women were diagnosed with late-stage and harder-to-treat cancers. Rates for advanced cancers decreased by 11% in states that expanded Medicaid under Obamacare.
For women on Medicare, screening mammograms are free as long as their doctor accepts assignment, meaning they agree to charge no more than what Medicare recommends. Transgender individuals are also covered if the mammogram is considered medically appropriate based on their situation.
Mammograms and Dense Breasts
Breasts are composed of fatty, fibrous, and glandular tissue. Mammograms look at this tissue using X-rays. Fat appears dark on X-rays, while glands and fibrous connective tissue appear white. Cancerous changes, like clusters of calcium (breast calcifications) or tumors, can look white too.
Screening vs. 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.
As many as 48% of women have dense breast tissue. To be clear, dense breasts are a radiologic finding, not something you can feel.
Dense tissue appears whiter on mammograms because it contains either less fat or there are areas of more fibrous and glandular tissue. Having dense breasts can make it harder for a radiologist to see small changes that could be related to cancer.
Unfortunately, women with dense breast tissue are at higher risk for breast cancer. Not only that, traditional mammograms are not as effective at detecting cancer in these women.
Digital mammograms help by increasing the sensitivity of the test. Still, they are not as accurate as they are in women with less dense breasts.
Breast Implants
Breast implants, whether they are saline or silicone, can sometimes make it tricky to detect cancer on a mammogram. Even when techniques are used to gently move the implants toward the side, they could still physically obstruct the view.
What Is Sensitivity?
Sensitivity, also known as the true positive rate, is the ability to detect disease in a person who actually has the disease. A test that has high sensitivity is less likely to give a negative result when you have cancer. The higher the sensitivity, the better.
If there are any questions about the images on a mammogram, a radiologist may recommend a breast ultrasound to get a detailed view.
Likewise, some women can develop complications from their breast implants. This can include anything from breast pain caused by scar tissue around the implant (capsular contracture) to a decrease in breast size from a leaking or ruptured implant. A breast ultrasound may be helpful to assess these situations too.
Breast Cancer in Men
Screening tests for cancer are done 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, or a history of radiation to the chest for treatment of another cancer.
Regardless of risk, if a person develops symptoms, they should be evaluated with diagnostic imaging. Symptoms may include breast pain, a breast lump, skin changes, or unexplained nipple discharge.
Mammograms are the preferred imaging test, but many men do not have enough breast tissue to have the test. An ultrasound makes sense as an initial imaging test.
Pros and Cons of Breast Ultrasound
When there are questions about a mammogram finding or a mammogram cannot be performed, a doctor may recommend a breast ultrasound to get more information.
Cisgender and Transgender
Transgender (gender identity differs from that assigned at birth) women on estrogen therapy have a risk higher for breast cancer than cisgender (gender corresponds to that assigned at birth) men, but a lower risk than cisgender women.
A breast ultrasound is a relatively low-cost test that uses sound waves to generate an image of the breasts. It is hard to detect small abnormalities like breast calcifications on ultrasound, but it can be a helpful test for people with cysts, masses, and breast implants.
Using a mammogram and breast ultrasound together improves the detection of breast cancer in people with dense breasts. One study shows that sensitivity increased from 74% with mammogram alone to 96% when both studies were used.
More breast cancers are detected thanks to breast ultrasound. Case in point, states with dense breast notification (DBN) laws have seen an increase in the number of ultrasounds performed and the number of cancers diagnosed.
These laws require a letter be sent to anyone whose mammogram shows dense breast tissue, even if their mammogram was otherwise “normal,” to let them know about their increased risk for cancer.
Unfortunately, breast ultrasounds increase false positive results too. This means that people who do not have cancer could be told they might have it. This can lead to unnecessary worry and testing.
Medicare Coverage for Breast Ultrasound
Medicare pays for tests it considers to be medically necessary. With that in mind, it is not surprising that Medicare covers breast ultrasounds for anyone who has symptoms.
However, unlike a screening mammogram, the test will not be free. Mammogram is the only screening test for breast cancer that has a $0 price tag. You will pay 20% toward the cost of a breast ultrasound if one is deemed medically necessary.
A breast ultrasound is a diagnostic test because it is ordered based on an abnormal finding, namely because of symptoms you have or dense breasts on a prior mammogram. Because it is not considered a screening test in the eyes of Medicare, it cannot be ordered as one. If your healthcare provider attaches a screening code to the order for a breast ultrasound, Medicare may not cover it. The test will only be covered if the order is attached to a diagnostic medical code that explains why the test is needed, i.e., a symptom or abnormal exam finding.
You may not have to pay for the test if you have a Medicare Supplement plan, also known as Medigap. These plans help pay for any out-of-pocket expenses that Medicare leaves behind.
If you pick a plan that covers the Part B coinsurance (Medigap plans A, B, D, F, G, M, and N), the plan will pay the 20% for you. Plan F is no longer available to people new to Medicare, but if you were on this plan before 2020, this would cover the Part B coinsurance too. Plans K and L only cover 50% or 75% of your coinsurance.
Summary
Mammograms are an effective tool for breast cancer screening, but they may not be enough for everyone. Cancer can be missed in women with dense breasts. Likewise, women and men with high risk factors or symptoms might need a closer look than a mammogram alone can offer. Medicare covers breast ultrasound for this very reason.
A Word From Verywell
Screening for breast cancer or diagnostic imaging if you have a concerning symptom can save your life, as early detection is the best chance for a good outcome. As always, it is important to talk with your doctor. Together, you can discuss your personal risk factors and decide whether a breast ultrasound is right for you.
