Insurers must pay for ‘medically necessary’ 3-D mammograms

Health insurers must cover “medically necessary” high-tech 3-D mammograms without copays, coinsurance or deductibles under a new state law, Gov. Andrew M. Cuomo’s office said Thursday.

The payment stipulations, signed by Cuomo, amend New York Insurance Law and add to measures the governor signed last year to enhance breast cancer screening.

“We will continue working to further remove barriers to breast cancer detection and treatment to create a stronger, healthier New York,” Cuomo said in a statement.

A Cuomo spokeswoman Thursday clarified the state’s definition of the term medically necessary. When it comes to 3-D mammography, the new payment rules apply when the test is deemed “medically necessary as determined by a physician.”

Three-dimensional mammograms have been a point of contention between patients and their insurers ever since the technology was federally approved six years ago. A 3-D mammogram, also known as tomosynthesis, is a digital, low-dose X-ray exam that dramatically increases tumor detection because it can image tissue in multiple angles. The exam also decreases false positives.

Some insurers, however, do not cover 3-D mammograms, doctors said Thursday, although 2-D mammograms are covered at no charge to patients insured by a number of companies, including those providing insurance under the Affordable Care Act.

The charge for a 3-D mammogram can range from $75 to $120, which Medicare began covering in 2015 for women 65 and older. Some doctors worry the wording of the state’s approval may dissuade patients from undergoing the most effective test.

“They’re saying when medically necessary. That’s creating a gaping loophole,” said Dr. Steven Mendelsohn, chief executive of Zwanger-Pesiri Radiology, which has more than a dozen facilities on Long Island. “It will create confusion because women will think the state approves it, but insurance companies can still deny it.”

“I think all mammograms are medically necessary,” Mendelsohn said, noting that diagnostic mammograms, those recommended by a doctor, are performed to examine a lump, fluid discharge or other abnormality. Women without symptoms undergo a routine screening mammogram as part of a physical exam.

“Well-documented studies have shown a 41 percent increase in detecting ductal carcinoma. And 3-D mammography reduces the recall rate,” Mendelsohn said of patients having to return for further testing.

“A third benefit that people really don’t talk about is that it increases the confidence rate of radiologists when they use the word normal. When you get a 3-D mammogram it allows the radiologist to be 100 percent certain about using that word,” Mendelsohn said.

Over the long haul, insurance companies can save money by covering the technology, he added, because patients are not asked to come back for additional tests, including unnecessary biopsies, he said.

In Washington, D.C., Linda Goler Blount, president and chief executive of the Black Women’s Health Imperative, praised Cuomo and New York State for making 3-D mammograms more affordable. The test has been a highly effective method of screening dense tissue, which can obscure a tumor, she said.

“It is a bold step for a state to require insurers to cover 3-D mammography with no cost-sharing,” Blount said.