Why do insurance co. not cover mammograms unless your 40!?

Question

You have to be 40 years old before insurance companies will cover a mammograms. That seems irresponsible since there are thousands of women under 40 that have breast cancer and they would have to wait till 40 to receive their first mammogram. Even though my mom had cancer that wasn't enough for them to help pay for my first mammogram. I had to wait another year before finding a lump in my breast and my doctor had to write that it was necessary before they would approve an appointment.
I don't have cancer as far as I know. But after my mom went in 6 years in a row throughout the 80's for mammogram with a lump that went from marble to golf ball size- they were only able to diagnose cancer on the second biopsy and by that time it had spread to her lymph-nodes under her arms. So I am skeptical of the entire process and even though my mom is missing both her breasts now- I for see that no matter what happens I will most likely have the same result or worse death.

Answer 1

Mammogram is a screening tool. Large studies in Europe and America first showed that doing routine mammograms in women helped decrease breast cancer mortality, first with a cutoff age of 50 and above, and then later there was some benefit shown for women age 40 and above. Further evaluation to detect whether evidence existed for routine screening at ages less than 40 showed no benefit.

A screening exam is judged to be useful if it is inexpensive and effective at detecting early stages of disease over a large population. Insurance companies are essentially obligated to promote and support routine screening exams because early detection and treatment of disease (especially cancer) is much cheaper and more effective than waiting until the disease is causing problems.

If a doctor feels as though a study is warranted because of specific clinical concerns, then insurance companies are typically going to evaluate the recommendation and then consider whether or not they are going to cover the cost. In the case of a woman with a family history of multiple women who have had a breast cancer diagnosis early in life, an early program of screening is appropriate (before age 40, in fact at or before the age of cancer diagnosis in the relatives).

In the case of women who have specific findings of concern (for example a mass that can be felt on exam), mammography is no longer a screening tool, now it's a DIAGNOSTIC tool. The rules for diagnostic mammography are completely different than the rules for screening mammography.

For a doctor to get an insurance company to cooperate, they must document their findings and the reason for the exam that is being ordered (such as mammogram). If the insurance company still refuses, the doctor can often fix the problem by contacting the insurance carrier directly and speaking to a manager. I have done this many times, and my record is pretty good at getting them to cooperate. However, it all comes down to one's ability to communicate, and as you can see from th explanation above. I have no problem explaining myself!

In the end, mammography is a comparitively inexpensive exam. If a doctor thinks that perhaps a mammogram might be helpful but that it's a soft call, then paying for it out of pocket is a completely reasonable alternative when the insurance company denies it.

Answer 2

In Brazil, insurance will pay for your mammograms regardless of your age.
While it´s true that getting a mammogram will expose you to radiation, which can cause cancer, doctors should always weigh risks and benefits when deciding to prescribe one or not.
If your mother had breast cancer, you should start getting mammogram early. You could also get DNA testing -- you can find out of you have a gene that increases your chance off having breast cancer. In any case, I don´t understand why the richest country in the world has cuch a bad healthcare system. I have lives in the USA for 10 years, and was very surprised to find out that most Americans don´t have access to good healthcare. If I were American, I would try to change that, even though it´s easier said than done!
Good luck!

Answer 3

I am a coding specialist at an imaging center. I can tell you that most insurance companies will pay for a mammogram assuming that your script supports a diagnostic mammogram.

I don't know how old you are, but did your doctor recommend a breast ultrasound at all? We wouldn't even do a mammogram on a woman in their 20's before an ultrasound.

Answer 4

I do not know about other countries. In India no insurance Company is paying for any tests or procedure conducted for identifying the disease. Mammogram is the test done to detect breast cancer.

Why you are bothering for the reimbursement from Insurance Co. Mammograms does not cost much comparing to other treatments if cancer is detected. You can pay it yourself.So do not bother.

KILL CANCER - Best of Luck

Answer 5

I agree with you, the mammogram should be included with the yearly check up. I really don't understand why it isn't.
Diagnosed with BC myself I meet a lot of women that are way under 40 so it is very common.
Insurance companies just don't want to pay for anything if they can help it.

Answer 6

Do you have other women in your family with breast cancer? Not all women that get breast cancer get it because of the gene. There seem to be environmental factors as well that cause breast cancer. My daughter is at increased risk because three of her grandparents had breast cancer - grandmother and grandFATHER on her dad's side and my mom. I see a breast surgeon every six months (cysts and fibrous tissue that can mask tumors) and she advised that my dauther get tested for the gene when she gets a bit older and to be diligent with monthly breast self-examinations. In younger women, mammograms are not as effective at detecting tumors because the breast tissue is so dense. This causes a lot of extra testing and extra exposure to radiation. Fortunately there are a lot better tests now and ultrasound and PET scans also. October is breast awareness month. Many places offer mammograms at low or no cost during this month for women without insurance. Check your local health care and women's clinics during this month and see if you can take advantage of this as well. Depending on your age, you may also want to see if you possess the BR-CA1 gene (I'm a bit fuzzy on its name). This gene also causes women to be at increased risk for ovarian cancer - which can be more difficult to detect because there are very little symptoms to look for to indicate early disease. Usually ovarian cancer is advanced when diagnosed. Arm yourself with information and best wishes for a long and healthy life.

Answer 7

I would check with your state insurance commissioner’s office (link below). I’ve also included a link to an Illinois Women’s Insurance Fact sheet. It talks about recent legislation that allows for coverage of baseline mammograms between ages 35 and 39 and coverage of mammograms for younger women who have a family history of breast cancer. Call your insurance office or check out their Web site to see if these regulations apply in your state, and make sure your doctor thinks it’s medically necessary for these early diagnostic tests.

If you’re looking for a new health plan, check out MostChioce.com. You can review online health plan rates and speak with locally licensed health insurance agents without cost, obligation, or pressure.

You can find MostChoice.com here:
http://www.mostchoice.com/health-insurance.cfm

Hope this helps,
Barnes@MostChoice

Answer 8

I was 29 when I was diagnosed with breast cancer. My insurance has covered all of my mammograms, and all of my surgeries and treatments too. I am so sorry that you have gone through all of this with no support. I can't even imagine.....

Answer 9

I've had a similar experience. My mother died from breast cancer & at first the ins. didn't want to pay for my mammograms. My doctor insisted so now they do. You have to insist......the squeaky wheel gets the grease. In a similar scenario, I had fibroid tumors in my uterus & a cyst on my ovary. My gyn insisted it was nothing. (I've had them for over a year) I changed gyn's & now had a hysterectomy, at my urging. My daughter is an adult, so I don't need them anymore & don't have to worry about them becoming cancerous.

Answer 10

i think it sucks too....but being a cancer survivor and working in the medical billing field, i can tell you that the worst thing you can do is wait! your doc can diagnosis you as "family history of breast cancer" which will be covered by your insurance, or your doc can diagnosis as "premature -----" it just shows there may be something there that's questionable.

the bottom line is if your doc knows your family history, and you tell him you're concerned he will put a covered diagnosis on the order form for you so you can have a peice of mind. good luck :)