Medicare provides coverage for breast ultrasounds, but only when they are medically necessary and ordered by a doctor who accepts Medicare. This type of diagnostic imaging is particularly useful for individuals with dense breast tissue, as it can identify tumors that mammograms may not detect.

Original Medicare (Part B) covers one mammogram annually at no out-of-pocket cost. However, the policy for breast ultrasounds is different. Let’s explore Medicare’s coverage criteria, costs, and the situations where a breast ultrasound might be needed.

Why Did Medicare Stop Fully Paying for Breast Ultrasounds?

In 2024, Medicare revised its coverage rules for breast ultrasounds. It no longer fully pays for the test when the only finding is dense breast tissue with no other abnormalities.

Here’s why:

• Medicare considers dense tissue alone insufficient to justify additional screening.
• While dense tissue can obscure mammogram results, further testing like an ultrasound requires a doctor’s determination of medical necessity.

However, this change doesn’t mean breast ultrasounds are uncovered. Medicare typically pays 80% of the cost, leaving you responsible for a portion as a copay.

When Does Medicare Cover a Breast Ultrasound?

Medicare Part B and Medicare Advantage (Part C) plans cover breast ultrasounds under specific conditions. For coverage, the test must be considered medically necessary. Common situations where Medicare may approve a breast ultrasound include:

• Evaluating breast lumps in people who are pregnant or nursing.
• Checking for implant issues or complications.
• Planning radiation treatment for breast cancer.
• Assessing a hard-to-see mass that does not appear clearly on a mammogram.
• Distinguishing types of masses, such as cysts versus solid tumors.

Medicare-approved ultrasounds must be performed by a qualified medical technician or doctor, and they require a physician’s order.

How Much Do Breast Ultrasounds Cost Under Medicare?

The cost of a breast ultrasound varies depending on your Medicare plan and whether you have supplemental insurance. Below is a breakdown of typical expenses:

If you have a Medicare Supplement Plan (Medigap), it can help cover the 20% coinsurance and other out-of-pocket costs. Alternatively, Medicare Advantage plans may offer additional benefits, but your costs depend on the premium and deductible of your specific plan.

What Should You Know About Dense Breast Tissue?

Dense breast tissue is a common reason why doctors order additional imaging, such as ultrasounds, after a mammogram. It can obscure cancer on mammograms, making tumors harder to detect. Here’s what to keep in mind:

• Importance of follow-up imaging: If a mammogram shows dense tissue, your doctor might recommend a breast ultrasound to ensure no abnormalities are missed.
• Medical necessity: Medicare requires a physician’s order to determine whether further imaging is essential based on your unique circumstances.

Key Takeaways

• Medicare Part B covers one mammogram annually at no cost.
• Breast ultrasounds are covered when deemed medically necessary, such as for evaluating lumps, implant issues, or planning cancer treatment.
• You may be responsible for a copay and meeting the annual deductible for Part B.
• Supplemental plans, like Medigap, can reduce out-of-pocket expenses.

If you have Medicare Advantage (Part C), check your plan’s specific terms. Some plans may offer enhanced benefits or lower costs for breast ultrasounds. Always consult with your doctor and insurance provider to understand your coverage and potential expenses.

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