Earlier this year, a bill known as HB 1036 passed in the Texas House of Representatives and the Texas Senate and was subsequently signed into law by Texas Governor Greg Abbott. Sponsored by Texas Rep. Senfronia Thompson (D-Houston), the law requires all commercial insurance providers in Texas to cover the cost of digital breast tomosynthesis (DBT, also known as 3D mammography) for all patients.
Meanwhile, the American College of Radiology (ACR) estimates that as of May 2017, about 30 percent of mammography units installed in U.S. hospitals and imaging facilities were of the 3D variety, up significantly from a few short years ago. Moreover, research that focuses on the benefits of DBT continues to surface, with such advantages as cost savings, increased cancer detection rates and lower recall rates making a strong case for the radiology community and payors alike.
“The pluses far outweigh the minuses,” says Debra Monticciolo, MD, professor of radiology at Texas A&M Health Science Center College of Medicine in Bryan, Texas, vice-chair for research and section chief of breast imaging in the department of radiology at Baylor Scott & White Healthcare in Temple, Texas, and chairman of the ACR Breast Imaging Commission.
Legislation Is Heating Up
The Centers for Medicare and Medicaid Services (CMS) approved Medicare reimbursement for women undergoing DBT exams in conjunction with 2D digital mammography back in 2014. And on the state level, Texas legislators were not the first to board the DBT train in signing HB 1036 into law. Several other states already have similar legislation in place or are currently considering a bill that would require DBT coverage.
The scope of these laws does vary. For example, New Jersey has in place a breast cancer screening mandate that requires coverage of “certain breast evaluations, including ultrasound evaluation, MRI scan, DBT, and other additional testing of an entire breast or breasts.” In that state, members or covered persons in benefit plans who are subject to the mandate, as well as of administrative services only (ASO), ASC employee health, and self-funded groups that have opted to adopt the mandate, are considered eligible for DBT coverage after a baseline mammogram if the latter reveals extremely dense breast tissue or is abnormal within any degree of breast density (including not dense, moderately dense, heterogeneously dense, or extremely dense).
Also considered eligible for DBT coverage in New Jersey are individuals with additional risk factors for breast cancer. This includes a family history of breast cancer, positive genetic testing, extremely dense breast tissue based on the ACR’s Breast Imaging Reporting and Data System, or “other indications as determined by the member’s health care provider.” When DBT is deemed eligible for coverage, it is limited to “one procedure per mammographic episode of care, in either a screening or diagnostic role.” For benefit plans that are not subject to the mandate and for ASO, ASC employee health, and self-funded plans that have not adopted the mandate, DBT is considered investigational in the screening or diagnosis of breast cancer.