Patient Eligibility Criteria for Supplemental Screening for Breast Cancer, as Defined by State-Specific Legislation

Purpose: Breast cancer is a leading cause of death in women. Early detection is critical to reduce mortality, but dense breast tissue presents a diagnostic challenge. A study found that sensitivity of cancer detection in extremely dense or heterogeneously dense breasts was 51% and 59.8%, respectively, compared with 73.5% in almost entirely fatty breasts. Supplemental screening with MRI or ultrasound can be used to increase detection. However, many insurance plans do not cover supplemental screening in the absence of a legal mandate. There is no federal law requiring coverage for supplemental screening, so access to care depends on state laws. This study reviews how state-specific laws define patient eligibility for supplemental screening.

Methods/Materials: Each state’s legal code was examined for a mandate of insurance coverage of supplemental breast cancer screening. For each state that has a legal mandate, patient eligibility criteria for supplemental screening were recorded. It was noted whether dense breast tissue was listed as an indication for supplemental screening, and how this was defined. References to ACR, National Comprehensive Cancer Network (NCCN), or American Cancer Society (ACS) guidelines were recorded.

Results: As of May 2025, 34 states and the District of Columbia mandate insurance coverage of supplemental screening, with variation in how patient eligibility for supplemental screening is defined. Twenty-three states broadly establish eligibility through non-specific patient and family risk factors. BI-RADS density definitions are cited in 6 states’ laws. Four states’ laws mandate insurance coverage of supplemental screening in heterogeneously or extremely dense breasts without further defining the density categories. ACR guidelines are cited by 2 states’ laws, while 5 states’ laws reference NCCN or ACS guidelines. A few states narrowly define eligibility using specific risk factors.

Conclusions: Among the states that mandate insurance coverage for supplemental breast cancer screening, there is no uniform standard for patient eligibility, creating barriers to care. Patients will benefit from a federal standard for insurance coverage for supplemental screening with uniform eligibility criteria.