Will insurance cover breast Magnetic Resonance Imaging (MRI) for individuals with dense breast tissue?

From the Guidelines

Insurance coverage for breast MRI in individuals with dense breast tissue is often approved if they have additional risk factors for breast cancer, such as family history, personal history, or genetic mutations like BRCA1 or BRCA2, as supported by the most recent study from 2024 1. To qualify for coverage, a doctor's referral documenting medical necessity is typically required. Before scheduling a breast MRI, it is essential to contact the insurance provider to verify coverage and understand any requirements or out-of-pocket costs. Some states have enacted breast density notification laws requiring insurers to cover supplemental screening, but coverage policies remain inconsistent nationwide. The medical justification for supplemental screening is that dense breast tissue can mask cancers on mammograms, reducing sensitivity to as low as 30-50%, while MRI can detect cancers that mammography might miss in dense tissue, as highlighted in the study from 2021 1. Key factors influencing insurance coverage include:

• Breast density: Extremely dense breast tissue (category D) increases the likelihood of coverage.
• Additional risk factors: Family history, personal history of breast cancer, or genetic mutations like BRCA1 or BRCA2.
• Doctor's referral: Documenting medical necessity is crucial for approval.
• State laws: Breast density notification laws may require insurers to cover supplemental screening.
• Insurance policy: Coverage varies by provider and policy, so verification is necessary. The American Cancer Society advocates for MRI screening in high-risk women regardless of breast density, citing the higher sensitivity of MRI compared to mammography alone, as noted in the study from 2021 1. Overall, while insurance coverage for breast MRI in individuals with dense breast tissue may vary, the most recent and highest-quality evidence supports the use of MRI as a supplemental screening tool for those with additional risk factors, as stated in the study from 2024 1.

From the Research

Insurance Coverage for Breast MRI with Dense Breast Tissue

• Insurance coverage for breast Magnetic Resonance Imaging (MRI) in individuals with dense breast tissue varies, but there is evidence to support its use as a supplemental screening method 2, 3, 4.
• Studies have shown that breast MRI is effective in detecting breast cancer in women with dense breast tissue, with sensitivity ranging from 81% to 100% 2.
• The European Society of Breast Imaging (EUSOBI) recommends offering screening breast MRI every 2 to 4 years to women aged 50 to 70 years with extremely dense breasts 4.
• A cost-effectiveness analysis found that MRI screening is cost-effective for women with extremely dense breasts when applied at a 4-year interval, with an incremental cost-effectiveness ratio of €15,620 per quality-adjusted life-year (QALY) gained 5.

Factors Affecting Insurance Coverage

• The high cost of breast MRI and the use of contrast agents may be barriers to widespread use, but abbreviated MRI protocols aim to reduce costs and scan duration 6, 2.
• Insurance coverage may depend on individual circumstances, such as family history, genetic predisposition, and previous breast cancer diagnosis.
• The American College of Radiology and other organizations have guidelines for breast cancer screening, which may influence insurance coverage decisions.

Current Research and Recommendations

• Recent studies have demonstrated the effectiveness of breast MRI in reducing interval cancers in women with extremely dense breast tissue 3, 4.
• The DENSE trial showed that additional MRI screening resulted in a substantial reduction in interval cancers, with a cancer detection rate of 16.5 per 1000 screenings 3.
• The European Society of Breast Imaging recommends shared decision-making between women and their healthcare providers to determine the best screening method, taking into account individual preferences and values 4.