Insurance Denies Preventive Breast MRI Bill
A 43-year-old woman with a high breast cancer risk was billed $1,191.10 for a preventive MRI, despite pre-approval, because federal guidelines don't
Stephanie Halver, 43, was billed $1,191.10 for a preventive breast MRI last September. Her insurer, Blue Cross Blue Shield of Texas, pre-approved the scan but then refused to cover it as preventive care.
Halver's primary care doctor recommended the annual MRI after a risk assessment tool showed a high likelihood of future breast cancer. Her mother and aunt have had breast cancer, and she has dense breast tissue, both factors that increase risk. The MRI was scheduled six months after her yearly mammogram as an additional safeguard.
The High Cost of Prevention
Halver received the bill from Vancouver Clinic in Washington. She was confused because her doctor recommended the scan and her insurer pre-approved it. She assumed it would cost nothing, citing the Affordable Care Act's requirement to cover preventive care like mammograms.
Her confusion grew because a Washington state law requires many health insurers to cover breast MRIs. The issue stems from federal guidelines. The U.S. Preventive Services Task Force determines which screenings insurers must fully cover. This panel has found insufficient evidence to recommend routine breast MRIs for women with dense breast tissue who have a negative mammogram.
"I've had many phone calls trying to understand the bill," Halver said.
Cathy Peters of the American Cancer Society Cancer Action Network explained the distinction. Federal guidelines from the Health Resources and Services Administration consider additional imaging like MRIs as preventive only after an abnormal mammogram. For women like Halver with a high risk but no current abnormality, the scans don't qualify for mandatory no-cost coverage.
"Women who have not had an abnormal mammogram may end up running into a big bill," Peters said. This can deter future screenings. State laws often don't help because large, employer-sponsored plans are federally regulated.
Understanding Your Coverage and Costs
The financial details of Halver's bill were stark.
| Service | Total Charge | Insurance Payment | Patient Responsibility |
|---|---|---|---|
| Breast MRI | $1,205.00 | $13.90 | $1,191.10 |
| Injectable/Oral Medication | $65.60 | ~$32.80 | ~$32.80 |
Halver appealed the insurer's decision, but it was denied in July. Her employer's human resources department confirmed mammograms are fully covered under her plan, but breast MRIs are not. The MRI cost was applied to her $3,300 annual deductible.
"I think I'm on the hook for this bill," Halver said. With her ongoing high risk, she sees it as a guaranteed annual expense.
Ricki Fairley of the Black Breast Cancer Alliance recommends seeking a patient navigator for assistance. She urges women to use community resources or national groups to find ways to lower screening costs. Some state programs help low-income patients.
Other strategies include shopping around, as freestanding imaging centers may charge less than hospitals. Scheduling the MRI at the end of your health plan's deductible year can also reduce out-of-pocket costs if the deductible is already met.
The source for this report is KFF Health News.
