Before scheduling your supplemental breast imaging exam, take a few minutes to verify your insurance coverage. Doing so can help you better understand any potential out-of-pocket costs and avoid unexpected bills.
Before Your Exam
✔ Obtain an order from your healthcare provider.
A healthcare provider’s order is required for supplemental breast imaging.
✔ Ask the imaging center to verify your insurance coverage.
When scheduling your appointment, ask whether the imaging center can confirm that your insurance plan covers the exam and whether prior authorization is required.
✔ Know the CPT (billing) code.
Ask the imaging center or your healthcare provider for the CPT (Current Procedural Terminology) code for your exam. Insurance companies often use this code to determine coverage and estimate your financial responsibility.
✔ Contact your insurance company.
Have the following information available when you call:
- Your insurance member ID
- The CPT (billing) code
- The diagnosis (ICD-10) code, if available
- Your healthcare provider’s order
Ask:
- Is this exam covered under my health plan?
- Is prior authorization required?
- Will I have any deductible, copay, or coinsurance?
- Is the imaging facility in-network?
- Are there any restrictions or requirements I should know about?
What to Do if Your Claim Is Denied
If you believe your supplemental breast imaging should be covered by your insurance plan, don’t be discouraged if your claim is denied. Coverage decisions can sometimes be affected by billing errors, missing information, or differences in how insurance plans interpret coverage requirements.
Step 1: Contact Your Insurance Company
Before filing a complaint, contact your insurance company to better understand the denial.
Ask:
- Why was my claim denied?
- Can you provide a written explanation of the denial?
- Were the correct diagnosis and procedure (CPT) codes submitted?
- Was prior authorization required?
- Does my health plan include coverage under Wisconsin’s Gail’s Law or the HRSA Women’s Preventive Services Guidelines?
Step 2: File an Appeal
If you still believe your imaging should be covered, follow your insurance company’s internal appeal process. Many coverage decisions are successfully resolved through an appeal.
Step 3: Contact the Wisconsin Office of the Commissioner of Insurance (OCI)
If you are unable to resolve the issue with your insurance company, you may file a complaint with the Wisconsin Office of the Commissioner of Insurance.
Contact OCI
- Phone: 1-800-236-8517
- Email: ocicomplaints@wisconsin.gov
- Online: oci.wi.gov/Complaints
If contacting OCI by email, include your name, phone number, and a brief description of your concern. If you prefer to file by mail, you can request a complaint form through the website above or by calling OCI.
Before You File a Complaint
Having the following information available may help speed the review of your complaint:
- Your insurance card and policy information
- Your Explanation of Benefits (EOB), if available
- The denial letter or written explanation from your insurance company
- The date of your imaging service or claim
- Any correspondence you’ve had with your insurance company
- Your healthcare provider’s order or recommendation for supplemental breast imaging (if available)
Please Note
Insurance coverage for supplemental breast imaging depends on your specific health plan and individual circumstances. While Wisconsin’s Gail’s Law and the HRSA Women’s Preventive Services Guidelines have expanded coverage for many individuals, not every health plan is subject to these requirements.
For example, different coverage rules may apply to:
- Employer-sponsored self-funded (ERISA) health plans
- Medicare
- TRICARE
- Veterans Health Administration (VA) health benefits
- Other government or specialty health plans
If you’re unsure whether these laws or guidelines apply to your insurance, contact your insurance company or review the resources on this website to better understand your coverage options.
(August 2026)