Doctors knew there was no family history of breast cancer when they found the first sign of trouble on Claudia Strong’s mammogram.
“Even the medical staff at Crouse Breast Center commented on what an eagle eye my radiologist had to find this speck of cancer,” Strong recalls.
The tiny invasive cancer was detected with 3D technology called tomosynthesis.
“This was a screening examination. She had no symptoms, no mass, no complaints,” explained Dr. Stephen Montgomery who oversees breast imaging at the Falk Breast Health Center at Crouse Hospital. “You only have to look at that once and go ‘wow, I’ve got to have that.’ This is a revolution in breast imaging.”
Dr. Montgomery says his office has seen a 42 percent increase in detection of certain invasive cancers. Instead of one or two images gathered in standard mammograms, tomosynthesis technology can quickly capture dozens of slides about a millimeter thick, helping doctors see through dense tissue.
Similar results were found in international trials published by the journal Radiology, concluding: “The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.”
But, for some patients, 3D mammograms for an regular annual screening are not covered.
“It is heartbreaking for us when a woman comes back who has had the 3-dimensional tomo image last year and says ‘oh I want you to turn that off and just give me the two-dimensional because I got a bill last year because the insurance wouldn’t pay for the 3D,'” Dr. Montgomery says.
In June, a spokesperson for Humana explained their stance:
“3D is an emerging technology and the USPSTF (United States Preventive Services Task Force) currently does not endorse 3D mammograms as a preventative service. Our clinical staff continually reviews the peer reviewed, published literature as well as national and society guidelines and we will be reviewing the literature again this month (June). Medicare does cover 3D mammography and Humana does cover this service for our Medicare Advantage members.”
The USPS task force did not issue a recommendation for or against the technology.
The agency, which sets the bar for insurance providers, won’t issue an official endorsement either way without more studies, which might include closer reviews of higher radiation levels and rates of overdiagnosis with tomosynthesis.
Trials can take decades, a process the doctor feels is unethical in this case because it would involve limiting some participants to 2D screenings.
Some patients, like Claudia Strong don’t know they have more than one option for mammograms.
A United Healthcare spokesperson states:
“3D mammography is typically covered for our commercial members, but self funded clients can tailor their coverage as they deem appropriate.”
But, many employees are limited to the options laid out by large businesses that fund their own plans.
LIMITS ON NEW YORK’S NEW RULES
New York lawmakers enthusiastically began rolling out new rules this year. When state-regulated insurance plans are issued, renewed or modified in 2017, they are required to fully cover 3D mammograms without cost-sharing…to some degree. There are limits.
A closer look shows the new state policy doesn’t apply to many of the self-funded plans offered to employees through large companies.
A representative with the New York State Department of Financial Services says that’s because the state only regulates individually insured, small, and “some” large insurance plans. The rest fall under federal oversight.
Even with plans regulated by New York State, 3D mammograms are only fully covered when deemed “medically necessary” with diagnostic care….or when there’s a prior history of breast cancer for the patient or a first-degree relative with preventive care. Either way, a physician would need to recommend the 3D screening.
“So, their ‘out’ is to say ‘well it’s not medically necessary, so we don’t have to cover it,'” Dr. Montgomery adds. “We’ve been finding cancers 3-millimeters, 4 millimeters, unheard of small sizes with the new device. If a woman didn’t get a tomosynthesis we’d find her cancer, but not that year or maybe even the next year.”
His goal is to catch invasive cancer before “medically necessary” screenings are obvious with lumps or 2D technology.
Strong says she didn’t feel any symptoms before her tomosynthesis detection.
“I had no reason to suspect that I was going to find any cancer. My sisters don’t have cancer. My mother doesn’t have cancer. There was no reason, other than I knew that it was the right thing to do and thankfully I did it,” she says.
According to a DFS representative, people in state-regulated plans can file appeals with their insurance company if a claim is denied. If that doesn’t work, an appeal can be filed on the DFS website: http://www.dfs.ny.gov/
The spokesman says DFS has received a “handful” of consumer complaints. In three cases, consumers were helped in obtaining coverage; one case is still being reviewed. With two external appeals, where independent third-party medical experts review cases, the insurance denials were overturned. A third, new case, is still pending.
Consumers in New York who have questions about insurance issues can contact the Department of Financial Services Consumer helpline during regular business hours at 1-800-342-3736.
DEFINING COVERAGE
Dr. Montgomery wants the government to require insurers to make it simple…by offering regular 3D mammograms with no co-pays in all cases, so patients don’t get discouraged by a confusing maze of coverage.
Asked if 3D mammograms are covered by their plans, statements were offered by a handful of companies. But many seemed to stop short of declaring outright coverage for preventive care, across the board.
“Excellus BlueCross BlueShield’s commercial benefit packages cover digital breast tomosynthesis — without member responsibility for co-payments, annual deductibles or coinsurance — when following recommended screening guidelines and rendered by a participating provider,” wrote one spokeswoman.
“We do cover breast tomosynthesis without co-pay when done with a mammogram which does not require a copayment/coinsurance,” wrote a public relations representative for MVP Healthcare.
An Anthem Blue Cross and Blue Shield spokeswoman said:
“Empire has been providing benefits for digital breast tomosynthesis, also known as 3D mammogram, since earlier this year for insured members in its individual, small group, group and employer-sponsored plans. Medicaid plans cover this service consistent with state program guidelines. Empire is covering the 3D mammograms as both a diagnostic benefit and a preventive benefit for screening, which means that members would have zero co-pay for the service when provided in-network.”
Cigna seemed to take the first big step toward expanding coverage, a spokesman states: “Cigna covers 3D mammography. In fact, last year we were the first national insurer to start covering it for routine screening”.
Dr. Montgomery notes early detection is crucial for preventing death. In his office, he thinks the average difference in cost between 2D and 3D screenings is about $75.
“It was less expensive to pay for the Tomosynthesis than it was to treat women with more advanced disease. That’s crazy,” Dr. Montgomery says.
The doctors believes 2D technology would have detected Claudia Strong’s cancer…eventually.
“What would have happened in the year that it would have taken for me to have another mammogram?” Strong wonders. “We don’t know. Maybe I had a very slow-growing cancer, maybe I had a fast-growing cancer. Thankfully, we don’t have the answer to that.”
