Does Medicare Cover Ultrasound for Dense Breasts?

Medicare provides health coverage to millions of eligible individuals across the nation, primarily those aged 65 or older, and younger people with certain disabilities or end-stage renal disease. This federal health insurance program helps manage significant healthcare costs for its beneficiaries. Diagnostic imaging plays a fundamental role in modern healthcare, enabling medical professionals to detect and monitor various health conditions, especially for breast health.

Medicare Coverage for Breast Ultrasounds

Medicare generally covers breast ultrasounds when they are considered a diagnostic tool rather than a routine screening. This distinction is important because coverage focuses on medical necessity, meaning a physician must order the ultrasound to investigate a specific medical concern. Breast ultrasounds are not typically covered as a standalone screening method solely due to breast density without other clinical indicators.

Coverage for a breast ultrasound typically falls under Medicare Part B, which is medical insurance. This part of Medicare assists with costs for doctor’s services, outpatient care, and certain preventive services. For a breast ultrasound to be covered, it must be ordered by a healthcare provider who accepts Medicare assignment, and the order must include a diagnostic medical code explaining why the test is necessary.

Medicare usually covers diagnostic breast ultrasounds following an abnormal mammogram, when suspicious or inconclusive results require further investigation. It also covers ultrasounds to evaluate specific symptoms like a palpable lump, unexplained breast pain, or unusual discharge. Ultrasounds are also covered for follow-up of previously identified breast abnormalities to monitor progression or regression.

Dense breast tissue alone does not typically qualify for a screening ultrasound under Medicare. However, it can be a factor when combined with other clinical indicators. For example, if a mammogram is inconclusive due to breast density and other concerning findings or symptoms exist, Medicare may cover the ultrasound as a diagnostic procedure. The ultrasound helps differentiate between normal dense tissue and potentially cancerous lesions, which can be obscured on a mammogram.

Understanding Medicare Costs for Breast Ultrasounds

When Medicare covers a diagnostic breast ultrasound, beneficiaries are responsible for certain out-of-pocket costs. These costs are determined by Medicare Part B regulations. The annual Part B deductible must first be met before Medicare begins to pay its share of the approved amount for services.

For 2025, the standard annual deductible for Medicare Part B is $257.00. After this deductible is satisfied, Medicare Part B typically pays 80% of the Medicare-approved amount for the diagnostic breast ultrasound. The beneficiary is then responsible for the remaining 20% coinsurance.

Additional costs may include facility fees if the ultrasound is performed in an outpatient hospital department or a hospital-owned clinic. These fees cover the operational costs of the facility, such as equipment, space, and support staff, and are separate from the physician’s professional fees. The 20% coinsurance typically applies to both the facility fee and the physician’s fee for interpreting the ultrasound.

Supplemental insurance options, such as Medigap policies or Medicare Advantage Plans (Part C), can help manage out-of-pocket expenses. Medigap plans cover some or all costs Original Medicare does not, including deductibles and coinsurance. Medicare Advantage Plans, offered by private insurers, must cover at least the same services as Original Medicare but may have different cost-sharing structures, including varying deductibles, copayments, and coinsurance, often with an out-of-pocket limit.

Navigating the Medicare Coverage Process

Ensuring Medicare properly processes a breast ultrasound claim involves several key steps and considerations. The process begins with securing a physician’s order for the diagnostic ultrasound. This order is essential and must clearly state the medical reason for the procedure, such as a specific diagnosis or symptom, to establish medical necessity for Medicare coverage.

It is important to confirm that both the facility where the ultrasound will be performed and the interpreting physician accept Medicare assignment. Providers who accept Medicare assignment agree to accept the Medicare-approved amount as full payment for covered services. This arrangement helps protect beneficiaries from higher costs, as these providers cannot bill more than the Medicare-approved amount, limiting out-of-pocket expenses to the deductible and coinsurance.

While not always required for diagnostic ultrasounds, some specific situations or certain Medicare Advantage plans might necessitate prior authorization. Beneficiaries should always check with their healthcare provider and their specific Medicare plan to determine if prior authorization is needed to avoid unexpected denials. This proactive step can prevent complications in the billing process.

Providers typically submit claims directly to Medicare on behalf of the beneficiary. After the claim is processed, Medicare sends an Explanation of Benefits (EOB) or a Medicare Summary Notice (MSN) to the beneficiary. This document details the services received, what Medicare paid, and the amount the beneficiary owes. It is important to review the EOB or MSN carefully to understand the payment breakdown and identify any potential issues.

If a claim for a medically necessary diagnostic breast ultrasound is denied, beneficiaries have the right to appeal. The Medicare appeals process has five levels:
Redetermination by a Medicare Administrative Contractor
Reconsideration by a Qualified Independent Contractor
A hearing before an Administrative Law Judge
Review by the Medicare Appeals Council
Judicial review in a federal district court

Each level offers an opportunity to present additional information or argue for coverage.