Stephanie Halver’s primary care doctor used a risk assessment tool to calculate her chances of developing breast cancer, and the likelihood “popped up really high” due to her family history and dense breast tissue. Halver, 43, lives in Vancouver, Washington, and her doctor recommended an annual breast MRI, six months after her yearly mammogram, as an additional safeguard.
Halver’s situation is not unique, as actress Olivia Munn also had a breast MRI in 2023 that detected an aggressive form of cancer in both breasts, even though a recent mammogram had been clear. The National Cancer Institute states that catching breast cancer early improves survival rates.
A breast MRI is a preventive and diagnostic tool that captures pictures of breast tissue in higher detail than a mammogram, and may be recommended for patients at increased risk for breast cancer. However, the American Cancer Society notes that breast MRIs are not generally recommended for women at average risk, as they can yield false positives and subject patients to unnecessary follow-up tests.
Insurance Coverage and Billing Issues
Halver’s insurer, Blue Cross Blue Shield of Texas, preapproved the scan, but she still received a bill for $1,205, with her insurance covering only $13.90. The clinic also charged $65.60 for “Injectable/Oral Med,” which her insurance covered about half of.
Halver was confused by the bill, as she knew the Affordable Care Act requires health plans to cover preventive care at no cost to patients. She also thought her state’s law, which requires many health insurers to cover breast MRIs, would apply to her situation.
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However, the U.S. Preventive Services Task Force, which advises the federal government on recommended screenings, has determined that the current evidence is insufficient to assess the balance of benefits and harms of breast MRIs for women with dense breast tissue. This means that preventive breast MRIs are not required to be covered at no cost to patients.
Federal Guidelines and State Laws
Cathy Peters, senior director of state and local campaigns at the American Cancer Society Cancer Action Network, noted that federal guidelines differ for patients whose mammograms detect an abnormality. In these cases, additional imaging, such as ultrasounds and MRIs, are considered preventive and are recommended to complete the screening process.
Some states have enacted laws that require insurers to cover breast MRIs, but these laws generally don’t benefit patients like Halver who are enrolled in large, employer-sponsored insurance plans. These “self-insured” plans are regulated by the federal government, not by state lawmakers.
Peters stated that “sadly, these state-by-state laws,” Peters said, don’t “fix the federal problem.”
Appealing the Coverage Determination
Halver appealed the insurer’s coverage determination, but her appeal was denied in July. She contacted her employer’s human resources department and learned that mammograms are covered as a preventive screening under her health plan, but breast MRIs are not.
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Halver’s annual breast MRI will be subject to deductibles, coinsurance, and other cost-sharing requirements, with the cost of her breast MRI applied to her $3,300 annual deductible.
If your doctor or medical provider recommends an annual breast MRI in addition to an annual mammogram, consider researching your state’s coverage rules on the DenseBreast-Info website. The nonprofit organization maintains a map with up-to-date information on state laws about breast cancer screenings. Depending on where you live and what type of health plan you have, preventive breast MRIs might be covered at no cost. If it turns out you could be on the hook for a future bill, there are a few things you can do beforehand to potentially lower your out-of-pocket costs.
Lowering Out-of-Pocket Costs
Ricki Fairley, co-founder of Touch, the Black Breast Cancer Alliance, recommended first finding a patient navigator at the hospital or cancer center to assist you. She urged women to seek out resources in their communities or through national advocacy groups, including Touch, to find ways to lower screening costs. Programs funded by some states can help offset the cost of breast cancer screenings for low-income patients, Fairley said. Beyond that, shop around for the best price.
Blue Cross Blue Shield of Texas declined to answer questions about Halver’s benefits or bill.
