Her Breast MRI Was Approved, But That Didn’t Mean Her Insurance Would Pay

Key Points:

• Stephanie Halver, at higher risk for breast cancer due to family history and dense breast tissue, was advised to get annual breast MRIs in addition to mammograms, as MRIs can detect abnormalities mammograms may miss.
• Despite being recommended as a preventive measure and preapproved by her insurer, Halver was billed over $1,200 for the MRI because federal guidelines do not mandate insurance coverage for preventive breast MRIs in women without abnormal mammogram findings.
• State laws may require insurers to cover breast MRIs, but these often do not apply to large employer-sponsored self-insured plans regulated federally, leaving many patients like Halver responsible for significant out-of-pocket costs.
• Breast MRIs following abnormal mammograms are considered preventive and typically covered, but those done solely based on risk factors without abnormal findings face coverage challenges, potentially deterring patients from necessary screenings.
• Patients are advised to research state coverage rules, seek patient navigators or advocacy resources to reduce costs, shop around for imaging centers with lower fees, and consider timing scans to minimize out-of-pocket expenses.