Does Medicare Have Breast MRI Coverage?

Medicare coverage for a breast MRI is determined on a case by case basis. Although mammograms remain the first-line screening test for breast cancer, a breast MRI may be recommended for people at high risk for cancer or who have questionable findings on a mammogram and need other imaging tests to take a closer look at the breast tissue.

Although breast MRI is more expensive, studies have shown it may be more likely to detect cancer than other tests. However, certain criteria must be met to qualify for Medicare coverage and some costs may be your responsibility.

How Breast MRI Works

Breast magnetic resonance imaging (MRI) uses magnetic fields and radio waves to take a picture of the breast. There are no X-rays involved.

A contrast dye is injected into a vein to make areas with increased blood flow stand out more in the images. This is important because cancerous tumors tend to form new blood vessels around them that help them grow.

It was once thought that breast MRI had to be performed early in the menstrual cycle for premenopausal people. The belief was that hormonal changes affected blood flow in the breast that could decrease the test’s sensitivity.

However, newer studies have shown that is not the case. Breast MRI can be performed at any time, making scheduling much easier for many people.

Keep in mind that anyone with a previous reaction to contrast dye or who has underlying kidney disease should talk to their healthcare provider before getting the test.

High-Risk MRI Assessment Guidelines

When it comes to testing, MRI may be recommended for people who:

• Are at high risk for breast cancer
• Have had a suspicious abnormality on a mammogram
• Are suspected of having a ruptured breast implant
• Already have a breast cancer diagnosis

For people with a breast cancer diagnosis, detailed imaging may help in making treatment decisions.

MRI is more sensitive than a mammogram and breast ultrasound when used to screen females at a 20% or higher lifetime risk for breast cancer. The National Cancer Institute (NCI) offers a straightforward online tool to check your risk. It’s called the Breast Cancer Risk Assessment Tool.

The sensitivity for MRI in this population was 90%, but only 37.5% for mammograms or ultrasound. MRI also outperformed mammograms and ultrasound even when they were used together.

Below are some factors that can increase the risk of breast cancer in females.

Age

The risk for breast cancer increases as you get older. According to the American Cancer Society, 129 out of every 100,000 females are diagnosed with breast cancer every year. Between 2015 and 2019, the median age at breast cancer diagnosis was 62. 

Diethylstilbestrol Exposure

The drug diethylstilbestrol (DES) was used to treat pregnancy-related complications from 1938 to 1971. The drug is no longer given to pregnant people because it was found to increase the rate of cancer and other health conditions in women who took the medication and also in children who were exposed to DES during pregnancy.

Studies have shown that people who took DES during pregnancy had a 30% higher risk for breast cancer than other women. Their female children were also at increased risk for:

• Breast cancer—a 2% higher risk than the general population
• Cervical and vaginal cancers
• Pregnancy complications

Family History and Genetics

Certain people may be at increased risk for breast cancer based on:

• Their genetics, such as BRCA1 and BRCA2 genes
• Genetic conditions, such as Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome (or a first-degree relative with one of these syndromes)
• Family history of breast and/or ovarian cancer, especially in first-degree relatives (parent, sibling, or child)

Females with a BRCA-1 gene mutation have a 72% lifetime risk of developing breast cancer, and those with the BRCA-2 gene mutation have a 69% risk. These genes also increase ovarian cancer risk.

Medical Findings on Mammogram

A questionable finding on a mammogram may require further evaluation. If a radiologist is uncertain about something they see on a mammogram, they may recommend another kind of imaging study, like a breast MRI, to take a closer look. In some cases, they may recommend a biopsy (tissue removal to analyze in the lab) instead.

Some people with a history of breast cancer may have had surgery or radiation that can leave scar tissue in the area. Radiation to the chest of any kind (such as for Hodgkin’s lymphoma) may make a mammogram harder to interpret.

Radiation exposure itself could also increase the risk of cancer in the area. MRI is the best tool to differentiate between scar tissue and possible recurrent cancer.

Personal History of Breast Cancer

A past history of breast cancer in one breast, whether it was localized or at an advanced stage, increases the risk of developing breast cancer in the other breast. However, this statistic has been improving with advancements in breast cancer treatment.

A 2021 report found the five-year cumulative incidence of developing cancer in the other breast was from 1% to 2% in those diagnosed with first breast cancer from 2004 to 2016.

Race and Ethnicity

Breast cancer is the most common type of cancer in females of all races and ethnicities, affecting 1 in 8 females in their lifetime. However, Black women are more likely to present with advanced disease at the time of their diagnosis. They also historically have had a higher mortality rate than White women.

Black women also represent a higher percentage of women diagnosed with triple-negative breast cancer before 40 years old. This type of breast cancer is aggressive and has more limited treatment options.

Reproductive History

The more estrogen a female has been exposed to in their lifetime increases breast cancer risk. People who had menarche (their first menstrual cycle) before age 12 and/or had menopause (the end of their menstrual cycles) after age 55 have increased rates of breast cancer.

During pregnancy, people are not exposed to as much estrogen because their menstrual cycles are paused. For this reason, females who have never had children and, therefore, have had more estrogen exposure tend to have higher rates of breast cancer than people who have had a full-term pregnancy.

That said, people who have a first full-term pregnancy after age 30 have a higher breast cancer rate than females who have never been pregnant. This suggests that pregnancies earlier in life may be somewhat protective against breast cancer later in life.

Modifiable Risk Factors

The risk factors described previously are out of your control. The following are modifiable risk factors you can change:

• Alcohol use: Risks of breast cancer are higher with increasing alcohol intake. The lowest rate is in people who do not drink alcohol and increase as consumption increases.
• Hormone use: The risk for breast cancer is temporarily increased when a female takes oral contraceptive pills (birth control pills), but that risk goes away within five years of stopping the medication. People who choose to take hormone replacement during menopause, specifically with combined estrogen and progesterone, may have a small increase in breast cancer risk. Talk with your healthcare provider to determine if the benefits outweigh the risks.
• Physical activity: Staying active may help protect against breast cancer. Recommendations include 150 to 300 minutes of moderate-intensity aerobic activity, 75 to 100 minutes of vigorous aerobic activity, or an equivalent combination of each intensity each week. In addition, strengthening exercises and balance training are recommended.
• Weight: Females who are overweight or have obesity have higher rates of breast cancer after menopause than those without these conditions. Managing your weight has health benefits that go far beyond decreasing your cancer risk.

Breast Implants

Breast implants, whether they are saline or silicone, have not been associated with an increased risk for breast cancer. However, there are instances when a person who has silicone breast implants may benefit from a breast MRI. Compared to ultrasound or mammogram, MRI has the highest sensitivity and specificity for ruptured silicone implants.

Medicare Coverage for Breast MRI

Medicare does not cover breast MRI for everyone. To qualify for coverage, certain criteria must be met.

Beneficiary Eligibility 

Breast MRI has a local coverage determination (LCD). This means that the Centers for Medicare and Medicaid Services (CMS) has not approved the test for nationwide coverage, which is known as a national coverage determination (NCD). Instead, decisions for coverage are made case by case.

LCD guidelines from December 2023 limit breast MRI to the following types of cases:

• An axillary (armpit) lymph node is positive for cancer, but the source of cancer is unknown.
• Breast cancer has been diagnosed, but more detailed imaging is needed to guide treatment options.
• A silicone breast implant is ruptured.
• Someone with a history of breast surgery has scar tissue that may be hard to differentiate from a tumor.
• A standard workup for breast cancer was inconclusive.

Other Types of Covered Breast Screening

If you’re under 65 and receive disability benefits from Social Security, you get Medicare automatically after getting disability benefits for 24 months. In this case, Medicare covers one baseline mammogram for women 35–39 years old and annual mammograms for women 40 years and older. There is no age cap.

To be clear, Medicare specifically limits screening to women. Transgender individuals may also be covered if a screening mammogram is considered medically appropriate based on their biology and whether they have undergone hormonal or surgical procedures.

Diagnostic mammograms may be performed more often than every 12 months if your healthcare provider considers them medically necessary. These tests can be ordered for anyone who has an abnormal mammogram finding, a prior history of breast cancer, or symptoms related to the breasts.

Breast ultrasound is a diagnostic test and is not considered preventive screening according to Medicare. Again, someone may qualify for Medicare coverage for breast ultrasound if it is deemed medically necessary, such as in these cases:

• A person has dense breasts on a mammogram.
• A person of any sex or gender has breast-related symptoms.

Cost Factors

Breast MRI is one of the more expensive imaging procedures for cancer screening. That is one of the reasons many health plans, including Medicare, limit coverage for its use. 

The out-of-pocket cost for breast MRI will vary based on where you live. According to FAIR Health Consumer, a free database of healthcare costs, an MRI of both breasts on average costs $644 in New York, $626 in Chicago, and $1,510 in Los Angeles.

Keep in mind these rates represent the cost you would pay without insurance. The cost would be higher if a biopsy were performed at the same time.

Medicare Specifics: Parts A–D

Medicare is a federally funded health insurance program for adults over 65 and people with qualifying disabilities regardless of age. It is divided into four parts:

• Part A: Referred to as hospital insurance, Part A covers care you receive when you are admitted to the hospital as an inpatient or in hospice. Part A will pay for diagnostic tests performed during your hospital stay. You will pay a deductible for each hospital stay, $1,632 in 2024, that covers all hospital care up to 60 days.
• Part B: Known as medical insurance, this part of Medicare covers care you receive outside of the hospital or when you are under observation in the hospital, that is, not an inpatient. Part B covers your screening tests. Screening mammograms are free for women only, but any diagnostic tests, including breast MRI, can be performed on anyone with a medical need. Medicare covers 80% of the test cost (you will be required to pay 20%), assuming the doctor and the facility performing the scan accept Medicare.
• Part C: Part C is more commonly called Medicare Advantage. These plans cover everything Part A and B do but can also add supplemental benefits. Unlike Part A and Part B (referred to as original Medicare since they were the first parts enacted into law in 1965), Medicare Advantage plans are not run by the federal government. Instead, they are run by private insurance companies. While screening mammograms for women will still be free, the rates for diagnostic tests will be set by the insurance company.
• Part D: Part D provides prescription drug coverage. Like Part C, it is run by private insurance companies. These plans do not provide coverage for breast cancer testing, but they could pay toward medications used to treat breast cancer.

What to Do if Coverage Is Denied 

Not every test will be approved for coverage. Medicare could argue that a breast MRI is not medically necessary for your situation. If your healthcare provider feels that the test is needed, you may choose to seek an appeal. A letter from your healthcare provider and additional documentation may support your request.

The Medicare appeals process can be time-consuming, but unless you are willing to seek alternative financing or pay out of pocket, you may have limited options.

You may consider reaching out to the following organizations for assistance in finding affordable breast cancer screening and for making a case for an appeal:

Summary

Mammograms are an effective screening tool, but they are not always accurate in females with a high risk for breast cancer. This may include females with BRCA gene mutations, certain medical conditions, and a history of cancer that was treated with surgery or radiation. In those cases, breast MRI may be better able to detect small cancers.

It is also a helpful tool in investigating abnormalities found on a mammogram or in planning for treatment in people of any sex or gender who have already been diagnosed with breast cancer.

Medicare coverage of breast MRI is limited, and certain criteria must be met. Your healthcare provider may need to provide documentation to Medicare to show that you need the test.