BERNARDS TWP., NJ - A Basking Ridge woman whose life was "essentially" saved after undergoing a 3-D mammogram procedure is a perfect example of the dilemma faced by patients whose physicians recommend the exam, using a newer technology, that some insurance companies won't cover.
Last November, longtime Basking Ridge resident Donna Gervasio received a 3-D mammogram recommended by her radiologist, Dr. Ben Schneider of Summit-based Overlook Medical Center. The 3-D test detected breast cancer, which the traditional mammogram was unable to clearly show.
Dr. Schneider had urged Gervasio to receive the 3-D mammogram after viewing her inconclusive traditional mammogram.
“After having a double mastectomy, my breast surgeon said that I probably had this for a few years and that the 3-D [mammogram] was able to detect it and essentially save my life,” Gervasio said, sharing what she feels is an important story.
“In mammograms, we take images of the breast and traditionally we would take what is considered two-dimensional mammography that is the gold standard," Schneider said. He said Overlook Hospital has been "ahead of the curve" offering what is already an accepted technology of 3-D, [three-dimensional, or the technical term tomosynthesis] mammograms.
"Instead of simply looking at the traditional two-dimensional image of the breast, 3-D allows doctors to 'slice through' or 'page through' an image and see what lies beneath," Dr. Schneider added, explaining the technology that proved so valuable in Gervasio's case.
Luckily for Gervasio, her medical center did not charge her for the 3-D mammogram, even though she said it wasn’t covered by her insurance company.
Lifesaving procedure often not covered by insurance
However, many New Jersey women might not be so fortunate. Some insurance companies reportedly will cover the 3-D exams, and some will not, and others will extend coverage only in some cases. Gervasio's New Jersey-based insurer pays for some 3-D mammography exams, but not for the general screening population, according to Dr. Schneider and Caroline DeLaney, an advocate for the issue.
DeLaney pointed to a 2014 article about a study by The Journal of the American Medical Association indicating that 3-D mammograms were able to detect 41% more invasive breast cancers than traditional mammography. The 3-D mammography had already been in use for a few years by the time of the study.
Medicare already pays for 3-D mammograms. As of last month, the state of Pennsylvania now requires insurors in that state to pay for the procedure under Pennsylvania law. Women in Pennsylvania also were finding themselves in the position of having to pay for the 3-D mammograms even after their doctors had ordered the exams.
Gervasio and Dr. Schneider are among the many patients and local doctors who believe the tests should be available to women, and they want to get the word out about they believe why insurance companies should be covering 3-D mammograms.
“Most of the major insurance companies say there is insufficient evidence for the use of 3-D mammograms, which I believe to be a bit short-sighted," Dr. Schneider said. "There are many studies that show 3-D to be reproducible technologies demonstrating multiple benefits."
He said the two ‘win-wins’ of tomosynthesis are first and foremost, detecting the presence of breast cancer where it might not have been discovered, and secondly, reducing false positives. "Traditionally when a woman has a screening mammogram, we identify possible abnormalities. We don’t know for sure, but we recommend doing additional imaging to confirm that it is or is not a real finding." The use of 3-D mammography reduced those false positives, Dr. Schneider said.
Dr. Schneider said that while insurance payers are a bit hesitant to begin reimbursing for the 3-D mammograms, reproducible data about its benefits has produced evidence in worldwide, including in Europe as well as in the United States.
"I think the insurance companies have their own interest in mind to keep cost[s] down [by] doing their best not to reimburse, but at the same time the evidence [points] toward that they should be," Dr. Schneider said.
With Medicare covering the 3-D exam, he said that ultimately he believes insurance carriers will also pay for it.
However, as of this time, the average woman getting a mammogram does not know whether or not they would be reimbursed for tomosynthesis, Dr. Scheider said.
"Some insurance plans will and some will not," he said. "It’s almost like the hospitals or the radiology offices that offer the test have to potentially create two levels of care; those who want to pay for the 3-D test out of pocket and those who do not want to pay." The health professionals would be put in the position of deciding whether that is how they want to operate, he noted.
Some Insurance Companies Will Cover, Some Not
Around the country, In regards to insurance coverage of 3-D, some insurance companies across the country have made the decision to cover and reimburse the exam, while many still will not.
Dr. Schneider said that in Gervasio's case, her insurance company offers coverage for some women, but not all.
He offered the further clarification that insurance companies in New Jersey are required by state legislation to cover 3-D mammograms for women with so-called "dense breasts."
"The catch is, a woman can only get her 3-D mammograms covered by insurance after she has received a baseline mammogram that demonstrates she has dense breasts," Dr. Schneider said.
He added the caution: "Keep in mind that dense breasts is just one of the many risk factors for breast cancer, and 3-D mammography benefits women of all ages and breast densities."
- Linda Sadlouskos contributed to this story.