The question of whether insurance covers a 3D mammogram, also known as Digital Breast Tomosynthesis (DBT), does not have a single, universal answer. Coverage is determined by a complex interplay of federal law, state mandates, and the specific details of an individual’s insurance policy. A patient’s out-of-pocket cost can ultimately hinge on whether the procedure is classified as a routine screening or a follow-up diagnostic exam. Understanding these distinctions is the first step in ensuring access to this technology without incurring unexpected expenses.
What is 3D Mammography?
Digital Breast Tomosynthesis is an advanced form of X-ray imaging that captures multiple low-dose images of the breast from various angles. These images are then digitally reconstructed to create a three-dimensional view of the breast tissue, unlike a traditional 2D mammogram, which provides a single, flat image. This layered approach allows a radiologist to scroll through the breast tissue slice by slice, reducing overlapping tissue that can obscure abnormalities.
The ability to see through dense tissue with greater clarity is a major advantage, as dense breast tissue can mask small cancers on a standard mammogram. Studies show that adding DBT to a 2D mammogram increases cancer detection rates and decreases the number of false positives. Fewer false positives mean fewer patients are called back for additional testing, which reduces patient anxiety and healthcare costs.
Mandatory Coverage vs. Discretionary Coverage
A screening mammogram is a routine, preventative test performed on an asymptomatic patient. A diagnostic mammogram is ordered when a patient has symptoms, such as a lump, or needs follow-up imaging after an abnormal screening result.
Under the Affordable Care Act (ACA), most health insurance plans must cover preventative services, including annual screening mammograms for women over 40, without cost-sharing. This federal requirement, however, initially applied primarily to standard 2D mammography, creating a gap in coverage for the newer 3D technology.
Because of this ambiguity, numerous states have mandated that insurance providers cover 3D mammography for screening purposes. These state laws often ensure that the advanced imaging is covered at the same level as a 2D scan, meaning no out-of-pocket cost to the patient. If a patient’s scan is classified as diagnostic, however, it is no longer considered preventative care, and standard cost-sharing provisions typically apply, regardless of state law.
Understanding Out-of-Pocket Costs
Even when a 3D mammogram is covered, a patient may still face costs based on their insurance plan’s structure. A deductible is the fixed amount a patient must pay before their insurance begins to pay for covered services.
A copay is a fixed fee a patient pays for a specific service, while co-insurance is a percentage of the total cost that the patient is responsible for after the deductible is met. For a screening 3D mammogram, a patient’s cost might arise if the insurance plan covers the 2D portion fully but denies the 3D portion, which is sometimes billed separately as an “add-on.” This separate charge for the tomosynthesis component can range from a small fee to over a hundred dollars. For a diagnostic 3D mammogram, the patient is generally responsible for costs until their annual deductible is met, followed by co-insurance or a copay.
Steps to Confirm Your Specific Coverage
To avoid unexpected charges, patients should proactively contact their insurance provider before their appointment. Patients should inquire about the Current Procedural Terminology (CPT) code for the service they plan to receive.
The CPT code for a screening 3D mammogram is typically 77063, while diagnostic codes include 77061 or 77062. Asking for coverage confirmation by these codes clarifies whether the plan will pay for the procedure and if any co-insurance or deductible applies. Additionally, confirming that the imaging facility is considered “in-network” by the insurance provider is a necessary step to ensure the lowest possible rate of patient responsibility.