My insurance is denying a breast ultrasound I had done after my routine mammogram. The ultrasound was recommended to me due to dense breast tissue. Insurance says there isn’t sufficient evidence that this is more effective than mammograms in detecting breast cancer, thus it is being labeled as “investigational.” It’s $1,200, so it’s no small fee for us, and something that was recommended by the radiologist and likely will be for at least the foreseeable future, until my breast tissue changes.
—Am I totally dense?
Navigating insurance coverage can be incredibly frustrating — for doctors and patients alike. It can help to understand how your insurance company determines when they will pay for a service or test and how much they will pay for it. This discussion is specific to the U.S. health-care system; if you live elsewhere, you will have your own system to navigate.
Every individual service and test has a separate current procedural terminology (CPT) code. There are two different CPT codes for breast ultrasound, one for the whole breast and one for a limited area of a breast.
Your insurance company will pay the radiologist a pre-negotiated set fee for each of these codes, but only if the request meets the insurance company’s criteria for the test. This involves a second set of codes called diagnosis codes, or ICD-10. Every possible diagnosis has its own code. The code for breast cancer screening is Z12.31.
For each CPT code, your insurance company has a list of ICD-10 codes for which they will cover that test. My guess is that your insurance company does not cover a complete breast ultrasound — CPT code 76641— for the diagnosis “breast cancer screening” — ICD-10 code Z12.31. However, there may be other diagnosis codes for which they will cover a breast ultrasound. It is possible that, based on the radiologist’s reading of your mammogram, one of those other diagnosis codes applies to you.
You have two options. Your doctor can appeal the insurance company’s original denial by submitting additional coding and information, including the radiologist’s report requesting further testing. Alternatively, you can ask your doctor to resubmit the claim with new coding if it is applicable.
Most medical centers and radiology offices have staff to assist with this. Avail yourself of their expertise — this is what they do all day, every day, and they get very good at it. In my experience, submitting an appeal with the radiologist recommendation of any additional applicable diagnosis codes can be all it takes to get things sorted.
The takeaway: Navigating insurance coverage can be complicated and frustrating, but working with your doctor and radiology center, you may be able to appeal or resubmit for coverage of your breast ultrasound.
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I didn’t write this question but I could have and this answer is missing the mark for me. What’s the data behind the recommendation to get a the ultrasound in addition to a mammogram? If I don’t shell out big bucks for the ultrasound, because even if it’s coded differently it’s probably still going to be out of pocket on a high deductible plan, am I more likely to die from breast cancer? Maybe I should skip the ultrasound until I’m 50 or until our healthcare system doesn’t suck (whichever comes first)? In Illinois, insurance plans are required to cover the ultrasound for dense breast tissue, but if you live in Illinois and your company is based on another state the insurance company can still give you the middle finger when you ask about covering the ultrasound. What I want to know is is it worth it to go through all of this insurance BS? The question of effectiveness is never addressed on the answer.
I agree. I am curious the effectiveness of mammograms vs ultrasound.
Look for the article she wrote from earlier this year called “Are Mammograms Enough to Detect Breast Cancer?” for more info on that
I strongly agree with katiemay as written above…the question is SHOULD she go through with it, not how to try to finagle things to get one paid for. The USPTF, when they updated their mammography guidelines basically acknowledged that mammograms were not really designed to screen dense tissue (which, awesome…half of us have that), but that there is zero evidence that shows that ultrasounds as a substitute or an add-on improve outcomes for women with dense breasts and therefore they held back from recommending them. A lot of insurance companies, no matter how you code it, will require cost-sharing because there is technically no such things as a “screening” ultrasound, per the USPTF. The New York Times did a big expose this summer about how Medicare has doubled down on denying them for lack of evidence in women with dense breasts. The elephant in the room is that the only screening we are guaranteed to have covered is one that wasn’t really designed for about half the people who are supposed to be screened. How this isn’t scandalously unacceptable this far into breast screening programs is beyond me. Not to mention, it’s the women that pay for the “risks” as far as the high rate of false-positives for both types of imaging. This stuff isn’t free. One ultrasound will run you the ungodly amount of up to a grand (again, how this is ethical given how old the technology is) but a biopsy? Thousands. Sadly, I don’t believe imaging centers have any incentive to reduce the expense of this on our end, since this is how they make money. And the metastatic rate remains stubbornly fixed, despite early detection efforts. We need the research to be done, screenings improved to be more inclusive of ALL women’s anatomical make-up, and if they indeed work, clearly recommended and covered.