Medicare and Mammograms: What Is Covered?

Medicare and mammograms


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Breast cancer is the most common type of cancer in women and their second leading cause of cancer-related death. According to the American Cancer Society, one in eight women will have breast cancer in their lifetime. In 2021, as many as 281,500 women will be diagnosed with invasive breast cancer in the United States, and 43,600 will die from it.

It’s important to screen for breast cancer at regular intervals to detect cancer when it is most treatable. That’s why Medicare covers mammograms. How much you will pay depends on how often the test is ordered, why it’s ordered, and whether it’s labeled as screening or diagnostic.

What Is a Mammogram?

A mammogram is an imaging study that looks at breast tissue using a low-dose X-ray. The radiation exposure is far less than what you would receive from standard X-rays, making it a relatively safe test.

One breast is imaged at a time. The breast is compressed between two plates to spread out the tissue, making it easier to see any abnormalities. An X-ray beam is directed through the tissue, and an image is captured on a film or computer.

Fibrous and glandular tissue appear white on X-rays, while fatty tissue looks dark or black. A lump or tumor can be seen as an area of dense white tissue.

Breast calcifications, which can be common in women over 50 years old, also appear white. They may be scattered throughout the tissues and are small in size. Although they are usually benign, if they are clustered together or have irregular shapes, these calcifications could be indicators for early cancer.

Types of Mammograms

There are three different types of mammograms. Medicare covers all of them.

Conventional Mammogram

This type of mammogram is a standard X-ray that is processed on film. It is the least expensive to perform overall. It correctly detects breast cancer 79% of the time (sensitivity), but this rate may be lower for younger women or those with dense breasts.

False positives, where a possible cancer is detected when there is no cancer, occur in 9.5% of tests. Over the course of 10 years, about half of the people tested will have a false positive. This leads to further testing and biopsies.

Digital Mammogram

This type of mammogram is processed on a computer rather than film. Digital mammography has been found to be more effective than conventional mammography in women under 50 years old, women with dense breasts, and premenopausal or perimenopausal women.

3D Mammogram

Also known as digital breast tomosynthesis, this type of mammogram adds dimension to the study. Rather than looking at the breast using a single flat image, the computer scans the breast in a series of layers that are then synthesized into a 3D model. Your provider may be able to visualize an area of concern with more detail.

Studies have found that tomosynthesis increases the detection of invasive breast cancer by 51% when compared to digital mammography alone.

Screening Mammograms

When the Affordable Care Act was passed in 2010, certain preventive screening tests were made free to people on Medicare. The catch is that your healthcare professional has to order the test, and they have to agree to the Medicare fee schedule.

Screening mammograms aim to detect breast cancer in women who do not have symptoms. As a preventive screening test, the goal is to diagnose cancer early enough in its course that it can be more easily treated and, hopefully, cured.

For transgender individuals, Medicare covers routine preventive care, including mammograms, as long as the care is clinically necessary for you. This is true no matter what the gender marker is in your Social Security records.

Screening recommendations vary depending on the medical organization. The American Cancer Society recommends annual screenings to start at 45 years old, with an option to decrease to every two years starting at age 55. Screening between ages 40 and 44 is optional.

The U.S. Preventive Services Task Force (USPSTF) recommends screening every two years for women between 50 and 74 years old, with an option for screening in the 40s.

Medicare Billing

Medicare uses months, not years, for its coverage requirements. If you have a repeat screening mammogram in 11 months, even if it is in a different calendar year, the study will not be free. You will be expected to pay the 20% Part B coinsurance.

Medicare is generous when it comes to breast cancer screening. A woman can receive one screening mammogram between 35 and 39 years old. After she turns 40, screening mammograms are covered every 12 months. There is no cutoff age for screening, and she can continue to be tested as long as she lives.

Diagnostic Mammograms

Diagnostic mammograms are performed when there are symptoms. This could be a lump on a self-exam, discharge from the nipple (especially if a woman is not breastfeeding), skin changes over the breast or nipple, a change in the size of the breast, or breast pain. It could even be done to follow up on an abnormal screening mammogram.

For obvious reasons, it would be unsafe to delay the test. There could be underlying cancer that requires urgent treatment. This is why there are no frequency limits on diagnostic mammograms. As long as the study is considered medically necessary, Medicare will cover it.

Unlike screening mammograms, however, these studies will not be free. After you pay down your annual Part B deductible ($203 in 2021), you will pay 20% of the cost of each test.

Surveillance Mammograms

There is controversy over whether surveillance mammograms should be considered screening or diagnostic tests. These mammograms are intended for women who have already been treated for breast cancer.

Whether women have had breast-conserving surgery (surgery to retain the breast, sometimes called a lumpectomy) or a mastectomy (surgical removal of all or part of the breast), their healthcare professional may want to monitor for cancer recurrence. They may also want to look for cancer in the opposite breast if cancer was originally found in only one.

Some providers consider surveillance mammograms to be diagnostic because a diagnosis for breast cancer has already been made. The risk for cancer recurrence or spread comes with the original diagnosis.

Others see it as a screening test since the cancer was already treated and eradicated. Any recurrence could be considered a new cancer and would require its own targeted treatment.

You will want to talk to your doctor about how they are ordering the test. It could affect how much you pay.

A Word From Verywell

Medicare covers both screening and diagnostic mammograms at a low cost to its beneficiaries. Be sure to get screened for breast cancer at the recommended intervals. If you have symptoms, do not hesitate to reach out to your doctor for an evaluation.

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Article Sources
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