Her Breast MRI Was Approved, But That Didn’t Mean Her Insurance Would Pay

Stephanie Halver, a 43-year-old resident of Vancouver, Washington, received a breast MRI recommendation from her primary care doctor after a risk assessment revealed her high likelihood of developing breast cancer. This was due to her family history, as her mother and aunt had both had breast cancer, and her dense breast tissue.

Halver's doctor advised her to get an annual MRI, in addition to her yearly mammogram, as MRIs can sometimes detect abnormalities that mammograms miss. One notable example is actress Olivia Munn, who had a breast MRI in 2023 that detected aggressive cancer in both breasts, despite a clear mammogram, and cited a high-risk assessment from her doctor as the reason for the recommendation.

Halver's insurance, Blue Cross Blue Shield of Texas, preapproved the scan in September, but the bill was quite surprising. After an initial $13.90 insurance payment, Halver was responsible for $1,191.10. The clinic charged $65.60 for an injectable or oral medication often used during the scan, and Halver's insurance covered about half of that cost.

Halver was confused, as she believed a preventive care recommendation would be covered at no cost to her, given the Affordable Care Act's mandate for no-cost preventive care services like mammograms.

The issue became clearer when she learned that while the U.S. Preventive Services Task Force, which advises the federal government, does not recommend breast MRIs for women considered at average risk due to potential false positives, those guidelines do not apply to women with higher risk factors. However, her insurance is self-insured, which falls under federal regulation, and these guidelines do not apply.

As a result, Halver's annual preventive breast MRI was not covered and was applied to her $3,300 annual deductible. Unfortunately, the appeal of the insurer's coverage determination was denied, leaving Halver with the responsibility of the $1,200 bill.