Medicare breast ultrasound

[RichardS431773]

Hi:

Apparently NGS Medicare LCD 11/2021

says that high breast density, family history, personal history of breast cancer, genetic testing risks are no longer criteria for secondary breast imaging by ultrasound or MRI for Medicare coverage. Even though most professional societies and some state laws say the opposite. Medicare now requires a lower standard of care for Medicare patients. 
For women with high risk factors and dense breasts and beast cancer this means a delay in diagnosis and a worse outcome. What is AARP doing about this travesty?

[KCN22999]

You photocopy the correct, accepted RX (and write on it the actual medical billing code accepted and/for whichever insurance, screening facility's will tell if asked).

Use this as reference each time, start with your primary doctor who writes the script. Do this each time the visit (every ?5 yrs), keep this stack of papers with you upon which ever visit Dr. or screening facility. It shows correct and proof, time date and service accepted. Its your back up, adjust as needed.

[GailL1]

@RichardS431773 

Maybe I am misunderstanding your post - but I don't think that this is what this coverage is saying at all at the coding end.

CMS.gov Medicare Coverage Database LCD ID L33950 Breast Imaging Mammography/Breast Echography (Sonog...

(For services performed on or after 11/25/2021)

See the heading Coverage Guidance in the above link.

There are (2) types of breast evaluations using imaging of one degree or another.  

1.  SCREENING - which is preventive in nature and is preformed when there are NO signs or symptoms.  

2.  DIAGNOSTIC - which is performed for a diagnosis when there are signs and symptoms.

They are each different in who can order them, interpret them, under what circumstances - in fact, the screening is a stepping stone to the diagnostic.

The medical scientific community (along with the government agencies) are always trying to get it right - thus the AHRQ and the more independent USPTF are continuing to find the best recommendations possible for screenings and when further establish when other types of diagnostic tools should be employed.

How did you come to your conclusion comment?

[RichardS431773]

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@GailL1 wrote:

@RichardS431773 

Maybe I am misunderstanding your post - but I don't think that this is what this coverage is saying at all at the coding end.

CMS.gov Medicare Coverage Database LCD ID L33950 Breast Imaging Mammography/Breast Echography (Sonog...

(For services performed on or after 11/25/2021)

See the heading Coverage Guidance in the above link.

There are (2) types of breast evaluations using imaging of one degree or another.  

1.  SCREENING - which is preventive in nature and is preformed when there are NO signs or symptoms.  

2.  DIAGNOSTIC - which is performed for a diagnosis when there are signs and symptoms.

They are each different in who can order them, interpret them, under what circumstances - in fact, the screening is a stepping stone to the diagnostic.

The medical scientific community (along with the government agencies) are always trying to get it right - thus the AHRQ and the more independent USPTF are continuing to find the best recommendations possible for screenings and when further establish when other types of diagnostic tools should be employed.

How did you come to your conclusion comment?

Hi Gail1:

thank you for your internet.

I got this interpretation from the NGS Medicare representative directly. Dense breasts, family history, personal history, genetic marker risk are no longer accepted indications for secondary imaging. In spite of a higher standard of care required for commercially insured patients, in spite of state laws . 

Medicare is federal and supersedes state laws.

Medicare is using their TPE protocol to enforce their interpretation on doctors and patients. As a cost saving attempt. Even though it will cost more in the end and will hurt patients ( cancers finally detected at a larger more advanced stage with a worse outcome). It’s tragically sad and foolish. I wish it were not so but it certainly is so!

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[GailL1]

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@RichardS431773 wrote:

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Hi Gail1:

I got this interpretation from the NGS Medicare representative directly. Dense breasts, family history, personal history, genetic marker risk are no longer accepted indications for secondary imaging. In spite of a higher standard of care required for commercially insured patients, in spite of state laws . 

Medicare is federal and supersedes state laws.

Medicare is using their TPE protocol to enforce their interpretation on doctors and patients. As a cost saving attempt. Even though it will cost more in the end and will hurt patients ( cancers finally detected at a larger more advanced stage with a worse outcome). It’s tragically sad and foolish. I wish it were not so but it certainly is so!

---

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Research is what counts here - especially with the government.  It was both the AHRQ and the USPTF that came to this conclusion -

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram.

They gave it a rating code of "I" - "Inconclusive" - 

https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening 

The AHRQ research study - Association of screening with digital breast tomosynthesis vs digital mamm...

Did you ever find (2) scientist that agree on anything?   Like I said, it is the research that matters to the government - of course, with the cost in mind since they pay for part or all of it.  Cost to benefits have to be part of the equation in healthcare for this reason - like in other countries - cost to benefits.

If this is a concern for you and the doc concurs - do it anyway, pay out of pocket if denied and then file an appeal with Medicare (CMS) to recoup.

[RichardS431773]

Medicare classified further imaging for dense breasts, etc as screening. Not covered. Only mammography is acceptable for screening.

Diagnostic studies require specific indications such as palpable mass, or a suspicious finding on a previous imaging study that requires further work up.

[spaniel4]

Yes, and women being sent home if the script is in the least bit “off”. I fought this and had luck,but I am a badger. Many women would cave in.

[RichardS431773 · Accepted solution]

If the RX is incorrect, that medical office will not be paid by Medicare or the insurance company for the work they honestly did. So of course patients are sent home in that case until the paperwork is properly done. 
you were able to badger them into doing it anyway. 

[spaniel4]

This type of response is uncalled for. The correct prescription was obtained via fax but it took some doing. Therefore I did not have to make the trip back and forth. The word badger is used to describe myself in a humorous way. All interactions with the staff were more than pleasant. Frankly you might be more careful in assigning the words you use. My point here was made to describe how complexities can make appropriate care difficult at times.