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Some Older Girls Want Additional Breast Scans. Why Received’t Medicare Pay?

Mammograms can miss tumors in girls with dense breast tissue. So for these sufferers, docs usually embrace a second scan — ultrasound, for instance, or an M.R.I. — which is extra prone to flip up cancers at early levels.

However some older sufferers are operating into an sudden twist. Although many ladies see the additional scan as a routine type of prevention, Medicare gained’t pay for it, and a few sufferers are left to choose up a hefty tab.

Joellen Sommer, 66, who lives in Manhattan, went for her annual breast most cancers screening in March. However the clinic’s workers mentioned that whereas her mammogram could be absolutely coated by Medicare, a so-called supplemental ultrasound was not.

Ms. Sommer has dense breasts, and a household historical past of breast most cancers. She mentioned she has acquired mammograms and ultrasound imaging all through her grownup life. “I simply don’t perceive how one thing that has been the beneficial diagnostic check for years is instantly not coated by Medicare,” she mentioned.

“My mom had breast most cancers, my aunt had breast most cancers — I assume that’s not sufficient,” she added. “I’m wondering if it was a check for males, if the identical difficulty would come up.”

Lenox Hill Radiology in New York Metropolis has began warning sufferers that if they’re insured by Medicare, they could be on the hook for as much as $450 in the event that they obtain a breast ultrasound, even when breast tissue is thought to be dense and the additional scan is carried out on the identical day as a screening mammogram.

An info sheet offered to physicians famous that Medicare does cowl breast ultrasound below restricted circumstances, equivalent to “to evaluate palpable or nonpalpable breast lots, ambiguous mammograms and different indicators or signs suggestive of breast most cancers.”

Steerage about when and the way usually to bear breast most cancers screening has modified over time, however mammograms, which use low dose X-rays to detect lesions, have lengthy been the gold customary for early detection.

However mammograms can’t really “see” tumors in dense breast tissue; each seem white in an X-ray. And dense breasts aren’t unusual: Whereas density declines with age, practically half of girls aged 40 and older who get mammograms are discovered to have dense breast tissue, in accordance with the Nationwide Most cancers Institute.

Breast tissue is taken into account dense when it has extra fibrous and glandular tissue, and fewer fatty tissue.

Beginning in September, all mammography facilities in the USA shall be required to tell sufferers who’re screened for breast most cancers if they’ve dense breasts. The hassle to attract consideration to the shortcomings of mammograms for these sufferers was began by girls whose personal cancers have been detected at a late stage, regardless of common mammography screenings.

Dense breast tissue is itself a threat issue for breast most cancers. Girls with extraordinarily dense breasts have twice the chance in contrast with those that have what is known as “scattered dense tissue,” or dense tissue right here and there within the breast, research have discovered.

Advocates say that for ladies with dense breast tissue, mammograms alone are “incomplete screening,” and a few scientists agree. Dr. Dorraya El-Ashry, chief scientific officer of the Breast Most cancers Analysis Basis, mentioned {that a} supplementary ultrasound is the present customary of take care of a secondary screening for dense breasts.

“In girls with the densest breasts, mammograms will miss about half of cancers current — half,” JoAnn Pushkin, govt director of DenseBreast-info, an academic group, mentioned.

The commonest questions the group receives are from girls attempting to navigate supplemental screenings, or discover out why they weren’t coated by insurance coverage, Ms. Pushkin mentioned.

“That’s a number of cancers being left on the desk, and a possibility missed to search out them on the earliest stage attainable, after they’re most treatable and survivable,” she added.

The group is supporting the Discover It Early Act, laws proposed by Consultant Rosa DeLauro, Democrat of Connecticut, and Consultant Brian Fitzpatrick, Republican of Pennsylvania. The measure would be sure that all medical health insurance plans cowl screening and diagnostic breast imaging, together with mammograms, ultrasounds and M.R.I.s, with no price sharing.

A spokeswoman for the federal Facilities for Medicare & Medicaid Companies mentioned its insurance policies haven’t modified: Medicare covers annual radiologic screening for ladies ages 40 and older at one hundred pc, as a part of preventive care.

However the company makes a distinction between mammograms and different screening exams, like ultrasounds, and they’re billed like diagnostic instruments, the spokeswoman mentioned in an e mail.

And there’s not common settlement on the worth of other screening for ladies with dense breasts. The American Faculty of Radiology says that 3-D mammography will increase the variety of cancers that may be seen with out extra testing, and that ultrasound and M.R.I. scans will help discover cancers that may’t be seen on a mammogram.

However neither the American Faculty of Obstetricians and Gynecologists nor the U.S. Preventive Companies Process Power has endorsed extra breast most cancers screening strategies for sufferers with dense breast tissue. There’s inadequate knowledge from medical trials to take action, the teams say.

There are additionally disadvantages related to supplementary screening strategies, equivalent to a excessive fee of false positives with ultrasounds, which trigger pointless anxiousness and follow-up care, and the excessive prices related to M.R.I. scans.

However in a letter final 12 months to the duty power, Ms. DeLauro and Consultant Debbie Wasserman Schultz, Democrat of Florida, mentioned a number of of the panel’s suggestions have put girls’s lives in danger, together with the duty power’s failure to “acknowledge the numerous physique of proof supporting extra screenings” for sufferers with dense breasts.

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