Breast
Appealing a denied diagnostic mammogram
Last reviewed July 1, 2026
A diagnostic mammogram (one done because of symptoms, callback, or dense breasts) is not automatically covered at 100% under ACA. But as of 2022, updated federal rules require most plans to cover follow-up imaging after an abnormal screening mammogram at no cost. And many states (17+ as of 2026) have passed laws requiring 100% coverage of diagnostic mammograms full stop. If you’re billed for one, the appeal path is well-worn.
The steps
Step 1: Find out if your state requires coverage. As of 2026, states with laws requiring 100% coverage of diagnostic mammograms include Arkansas, Colorado, Connecticut, Georgia, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, New Hampshire, New York, Ohio, Oklahoma, Oregon, Rhode Island, Texas, Virginia, Washington, and West Virginia. Check current list at densebreast-info.org.
Step 2: Cite the correct rule when you call. For follow-ups after an abnormal screening: cite the 2022 federal rule clarifying that supplementary services related to screening must be covered without cost-sharing. For any diagnostic mammogram in a state with a coverage law: cite that specific state law.
Step 3: File a written appeal. Include: the date of service, the CPT code (usually 77066 for diagnostic), the reason it was diagnostic (symptoms, callback, dense breasts, etc.), and the specific federal or state rule that requires coverage. Insurers must respond within 30 days.
Step 4: If denied on appeal, file a complaint with your state insurance commissioner. Contact info at naic.org. This step often unlocks the coverage — insurers hate state regulator involvement.
This applies when
- You had an abnormal screening mammogram and need follow-up imaging
- You have dense breasts and need diagnostic or supplemental imaging
- You have symptoms (lump, discharge, skin change) requiring diagnostic mammography
- Your state requires insurers to cover diagnostic mammograms at no cost
This doesn't apply when
- You're getting a routine screening mammogram with no symptoms, that's covered at 100% under ACA (see the screening mammogram guide)
- You don't have an abnormal screening result or documented clinical reason for diagnostic imaging
- You're on a grandfathered pre-ACA plan not subject to current preventive-care rules
Resources
Susan G. Komen Financial Assistance: For diagnostic imaging and treatment costs. komen.org or 1-877-465-6636.
CancerCare Copayment Assistance: cancercare.org or 1-800-813-4673.
DenseBreast-info.org: Comprehensive state-by-state coverage law tracker plus advocacy resources.
If you're denied
Written appeals go to the insurer’s appeals department (address on your denial letter). Include documentation of the diagnostic necessity from your provider. If your first appeal is denied, request an external review. The insurer must provide one, and external reviewers overturn denials roughly 40% of the time.
