This is great news that we are hopeful turns into a trend among other insurance providers.
In Ohio, the Ohio State Radiological Society (OSRS) is working with the Ohio Department of Insurance and state legislators to bring attention to this issue.
We have taken the position that tomosynthesis should already be covered under the current definition of “screening mammography” in the Ohio Revised Code which is as follows:
“Screening mammography” means a radiologic examination utilized to detect unsuspected breast cancer at an early stage in an asymptomatic woman and includes the x-ray examination of the breast using equipment that is dedicated specifically for mammography, including, but not limited to, the x-ray tube, filter, compression device, screens, film, and cassettes, and that has an average radiation exposure delivery of less than one rad mid-breast. “Screening mammography” includes two views for each breast. The term also includes the professional interpretation of the film. “Screening mammography” does not include diagnostic mammography.
The key words are “including, but not limited to”.
Other insurance providers that are currently covering Tomosynthesis, of which we are aware, include:
- All Ohio Medicaid/Medicare Providers
- Aultman Health
- ProMedica (Paramount Health Plan)
- Summa Health System (SummaCare)
Those providers that are denying coverage state the reason is that the technology is “investigational”.
However, the American College of Radiology (ACR) has determined that tomosynthesis is no longer investigational and CMS agrees along with many private insurers across the country.
From Cigna’s Medical Coverage Policy on Screening Mammography:
Digital Breast Tomosynthesis (DBT)
Large prospective and retrospective trials demonstrate the use of screening digital breast tomosynthesis (DBT) (3D mammography) in addition to 2D screening mammography (i.e., 2D) when used for annual screening provides a statistically significant increase in cancer detection rates (including invasive cancers) and a statistically significant decrease in recall rates compared to 2D mammography alone. Although long term studies on survival are lacking, it is reasonable to postulate from large prospective and retrospective trials that the addition of DBT may confer a positive impact on mortality. (emphasis added)
And finally, studies show that adding Tomosynthesis to 2D mammography is actually cost-effective to payers.
HealthImaging (8/23, Pearson) reports, “Adding annual screening tomosynthesis to 2D mammography beginning at age 40 is cost-effective compared with 2D mammography alone,” researchers found. The study, which “incorporated data from a multi-institutional study of more than 450,000 patients, institutional data of 13,000 patients, literature values and Medicare reimbursement rates,” revealed, however, that “net monetary benefits of the extra exam are around three times greater for women in their 40s than for those in their 50s and older.” The findings were published online in the American Journal of Roentgenology.
What are your experiences with Tomosynthesis? Do you cover the costs? Do patients have the option to pay out of pocket? Are insurers paying? Help us advocate for you by sharing your story. email@example.com; @OhioRadSociety; https://www.facebook.com/OhioRads