Does Medicare Cover a Breast MRI?

Estimated Costs and Next Steps If Coverage Is Denied

Breast cancer is the most common type of cancer in females, affecting 1 in 8 females in their lifetime. Males can get breast cancer and account for 1 out of every 100 cases.

Mammograms remain the first-line screening test for breast cancer. Even so, they may not detect all cases of breast cancer. People at high risk for cancer or who have questionable findings on a mammogram may need other imaging tests to take a closer look at the breast tissue.

While breast ultrasound (imaging using sound waves) is often used along with a mammogram, sometimes breast magnetic resonance imaging (MRI) will be recommended instead.

Although breast MRI is more expensive, studies have shown it may have higher sensitivity in people considered to be at high risk, meaning it may be more likely to detect cancer than other tests. This is not to say everyone should rush to get a breast MRI.

This article will review when breast MRI should be considered, how much it costs, and when Medicare covers it.

Radiology healthcare providers preparing for an MRI scan

vm / Getty Images

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.

What Are Sensitivity and Specificity?

Sensitivity and specificity are measures of a test’s accuracy. Sensitivity is a test’s ability to identify the presence of a disease in someone who actually has the disease, known as the true positive rate. The higher a test’s sensitivity, the more likely a positive test result means someone truly has the condition.

On the other hand, specificity is the test’s ability to correctly identify the absence of a disease, known as the true negative rate. Higher specificity means that a normal test is less likely to have missed something.

High-Risk MRI Assessment Guidelines

When it comes to testing, magnetic resonance imaging (MRI) is reserved for people at high risk for breast cancer.

It can also be used for people who have had a suspicious abnormality on a mammogram, for anyone suspected of having a ruptured breast implant, or for those who already have a breast cancer diagnosis. In those cases, the detailed imaging may help to make 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 for breast cancer in females.

Age

The risk for breast cancer increases as you get older. According to the American Cancer Society, 127 out of every 100,000 females are diagnosed with breast cancer every year. For females, the incidence is 2.1% for those younger than 49 years, 2.4% between 50 and 59, 3.5% between 60 and 69, and 7% when 70 and older.

Recommended Age for Breast Cancer Screening

The U.S. Preventive Services Task Force (USPSTF) recommends breast cancer screening with a mammogram every two years for females between 50 and 74 years old. Biennial screening may be determined on a case-by-case basis for females between 40 and 49.

Exposure to the Drug Diethylstilbestrol

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. Female children were also at increased risk for cervical and vaginal cancers, as well as pregnancy complications.

Family History and Genetics

Certain people may be at increased risk for breast cancer based on their genes (such as BRCA genes), medical conditions (such as Li-Fraumeni syndrome), or 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 for 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. Not only that but the radiation exposure itself could potentially increase the risk for cancer in the area. MRI is the best tool to differentiate between scar tissue and possible recurrent cancer.

Dense Breasts

Nearly half of women have dense breasts, as detected on their mammograms. This tissue appears whiter on mammograms, making it harder for a radiologist to find small cancers. Although women with dense breast tissue are at higher risk for breast cancer, breast MRI generally is not recommended for people in this group.

Breast ultrasound tends to be the preferred next step. When used with a mammogram, sensitivity is as high as 96%.

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 cancer for women of all races and ethnicities. 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 represent a higher percentage of women diagnosed with triple-negative breast cancer before 40 years old, as well. 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 as 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. You will need to decide if the benefits outweigh the risks.
  • Physical activity: Staying active may be help protect against breast cancer. You are encouraged to engage in moderate exercise at least three to five hours per week to decrease your risk.
  • 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 November 2021 limit the study 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

Medicare covers one baseline screening mammogram for women 35–39 years old and annual screening 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 was 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 in the eyes of Medicare. Again, Medicare will cover the test if it is deemed medically necessary. For example, a woman with dense breasts on a mammogram or a person of any sex or gender with breast-related symptoms may qualify for an ultrasound.

Screening vs. Diagnostic Tests

Preventive screening tests are intended to detect disease before symptoms develop. Once someone has an abnormal finding or symptoms, the test is considered diagnostic.

Cost Factors

Breast MRI is one of the more expensive imaging procedures for cancer screening. That is one of the reasons many health plans, Medicare included, 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 one breast on average costs $585 in New York, $565 in Chicago, and $1,017 in Los Angeles. For both breasts, it would cost $640, $618, and $1,500, respectively.

Keep in mind these rates represent the cost you would pay without insurance. The cost would be higher if both breasts were imaged or 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, $1,556 in 2022, 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. You will be required to pay 20% of the test cost in those cases.
  • 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.

Saving With Medigap

People on original Medicare (Part A and Part B, not Part C) have the option to sign up for a Medicare Supplement Plan, also known as Medigap. These plans are regulated by the federal government but are run by private insurance companies.

They help pay down costs that Medicare leaves on the table, including your co-pays, coinsurance, and deductibles (not your premiums). Depending on the Medigap plan you choose, they can pay your Part A hospital costs and 20% Part B coinsurance.

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.

Understanding that the health of many people is at stake if other imaging options are not made available to them, Medicare does cover breast MRI. However, that coverage 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.

A Word From Verywell

You may be tempted to ask your healthcare provider for a breast MRI, but the study is expensive and better suited to people who have a high lifetime risk for breast cancer. Medicare may cover the test if certain criteria are met, but you will be expected to pay 20% of the cost.

Frequently Asked Questions

  • Will Medicare cover an MRI for dense breasts?

    Medicare does not cover breast MRI simply because a female has dense breasts. Screening with a mammogram and an ultrasound is preferred in this case. The combination study is less expensive and has a high sensitivity for detecting breast cancer in these people.

  • Does an MRI or mammogram show breast cancer?

    These studies can detect abnormalities in the breast tissue that can be caused by cancer. Not all abnormalities, however, will be cancerous. The only definitive way to diagnose breast cancer is with a tissue sample. This is done by performing a breast biopsy.

  • What’s the difference between diagnostic and preventative breast screening?

    A preventive screening test looks for disease in people at risk for a condition but who do not have symptoms. A diagnostic test is performed when someone has symptoms or in follow-up to abnormal findings.

26 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. American Cancer Society. Breast.

  2. Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 2018;15(3 Pt A):408-414. doi:10.1016/j.jacr.2017.11.034

  3. Dontchos BN, Rahbar H, Partridge SC, Lehman CD, DeMartini WB. Influence of menstrual cycle timing on screening breast MRI background parenchymal enhancement and diagnostic performance in premenopausal womenJ Breast Imaging. 2019;1(3):205-211. doi:10.1093/jbi/wbz022

  4. Noreña-Rengifo BD, Sanín-Ramírez MP, Adrada BE, et al. MRI for evaluation of complications of breast augmentation. Radiographics. 2022;42(4):929-946. doi:10.1148/rg.210096

  5. Johns Hopkins Medicine. Breast magnetic resonance imaging (MRI).

  6. Riedl CC, Luft N, Bernhart C, et al. Triple-modality screening trial for familial breast cancer underlines the importance of magnetic resonance imaging and questions the role of mammography and ultrasound regardless of patient mutation status, age, and breast density. J Clin Oncol. 2015;33(10):1128-1135. doi:10.1200/JCO.2014.56.8626

  7. Gordon PB. The impact of dense breasts on the stage of breast cancer at diagnosis: a review and options for supplemental screening. Curr Oncol. 2022;29(5):3595-3636. doi:10.3390/curroncol29050291

  8. Siu AL; U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(4):279-296. doi:10.7326/M15-2886

  9. American Cancer Society. DES exposure: questions and answers.

  10. Kuchenbaecker KB, Hopper JL, Barnes DR, et al. Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2 mutation carriers. JAMA. 2017;317(23):2402-2416. doi:10.1001/jama.2017.7112

  11. EL-Adalany MA, EL-Metwally D. Detection of recurrent breast carcinoma using unenhanced breast MRIEgypt J Radiol Nucl Med. 2020;51(1):119. doi:10.1186/s43055-020-00230-1

  12. National Cancer Institute. Dense breasts: answers to commonly asked questions.

  13. Yuan WH, Hsu HC, Chen YY, Wu CH. Supplemental breast cancer-screening ultrasonography in women with dense breasts: a systematic review and meta-analysisBr J Cancer. 2020;123(4):673-688. doi:10.1038/s41416-020-0928-1

  14. Ramin C, Withrow DR, Davis Lynn BC, Gierach GL, Berrington de González A. Risk of contralateral breast cancer according to first breast cancer characteristics among women in the USA, 1992-2016. Breast Cancer Res. 2021;23(1):24. doi:10.1186/s13058-021-01400-3

  15. Richardson LC, Henley SJ, Miller JW, Massetti G, Thomas CC. Patterns and trends in age-specific Black-White differences in breast cancer incidence and aortality – United States, 1999–2014. MMWR Morb Mortal Wkly Rep. 2016;65:1093–1098. doi:10.15585/mmwr.mm6540a1

  16. Zagami P, Carey LA. Triple negative breast cancer: pitfalls and progress. NPJ Breast Cancer. 2022;8(1):95. doi:10.1038/s41523-022-00468-0

  17. Collaborative Group on Hormonal Factors in Breast Cancer. Menarche, menopause, and breast cancer risk: individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studiesLancet Oncol. 2012;13(11):1141-1151. doi:10.1016/S1470-2045(12)70425-4

  18. National Cancer Institute. Reproductive history and breast cancer.

  19. National Cancer Institute. Alcohol and cancer risk.

  20. Burchardt NA, Eliassen AH, Shafrir AL, et al. Oral contraceptive use by formulation and breast cancer risk by subtype in the Nurses' Health Study II: a prospective cohort studyAm J Obstet Gynecol. 2022;226(6):821.e1-821.e26. doi:10.1016/j.ajog.2021.12.022

  21. Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an Endocrine Society clinical practice guidelineJ Clin Endocrinol Metab. 2015;100(11):3975-4011. doi:10.1210/jc.2015-2236

  22. National Cancer Institute. Physical activity and cancer.

  23. Neuhouser ML, Aragaki AK, Prentice RL, et al. Overweight, obesity, and postmenopausal invasive breast cancer risk: a secondary analysis of the Women's Health Initiative randomized clinical trials. JAMA Oncol. 2015;1(5):611-21. doi:10.1001/jamaoncol.2015.1546

  24. Food and Drug Administration. Risks and complications of breast implants.

  25. Centers for Medicare and Medicaid Services. Local coverage determination (LCD): breast imaging mammography/breast echography (sonography)/breast MRI/ductography.

  26. Centers for Medicare and Medicaid Services. Mammograms.

By Tanya Feke, MD
Tanya Feke, MD, is a board-certified family physician, patient advocate and best-selling author of "Medicare Essentials: A Physician Insider Explains the Fine Print."