Does Aetna Cover Breast Ultrasound? Costs, Denials, and Appeals

Aetna does cover breast ultrasound under most of its commercial and marketplace plans, and as of January 1, 2026, a federal rule requires non-grandfathered plans to cover a breast ultrasound ordered to follow up on a mammogram finding with no copay, coinsurance, or deductible when you use an in-network provider. What you pay, if anything, depends on why the ultrasound was ordered, what kind of Aetna plan you have, and where you live. A standalone ultrasound ordered purely as supplemental screening for dense breasts, with no abnormal mammogram finding, may still involve cost sharing or a denial.

When Your Breast Ultrasound Should Be Free

On December 30, 2024, the Health Resources and Services Administration accepted updated Women’s Preventive Services Initiative recommendations stating that when additional imaging “is indicated to complete the screening process or to address findings on the initial screening mammography,” those services are recommended and should be covered. The guidelines name ultrasound, MRI, and additional mammography views as examples.¹

Under the Affordable Care Act, non-grandfathered group and individual plans must cover HRSA-supported preventive services without cost sharing when delivered in-network. The updated guidelines apply to plan years beginning on or after December 20, 2025, so most calendar-year Aetna plans have been required to cover follow-up breast imaging at no cost since January 1, 2026.²

Aetna has said it covers breast ultrasound “under either the medical benefit or the preventive benefit, in compliance with federal and state regulations and plan-specific benefits.”³ The practical result: if your mammogram turns up something that needs a closer look, and your Aetna plan is ACA-compliant and not grandfathered, the follow-up ultrasound should cost you nothing with an in-network provider.

When You Might Still Owe Something

The 2026 federal mandate has limits. It applies to women at average risk and focuses on imaging that completes an initial screening. It does not directly address a woman whose mammogram was normal but who wants an ultrasound because she has dense breast tissue. In that scenario the federal rule alone may not require Aetna to cover the ultrasound without cost sharing.⁴

The mandate also does not reach grandfathered plans (plans in effect before March 23, 2010, that have not made significant benefit changes), Medicare, TRICARE, or VA coverage. Aetna has pointed out that the U.S. Preventive Services Task Force found “insufficient evidence to support breast ultrasound as a primary screening recommendation,” which affects how certain ultrasound claims are categorized.³

Because plan designs vary, Aetna tells members to call the number on the back of the ID card for benefit specifics. The same procedure can be priced differently on an Aetna employer plan, an Aetna marketplace plan, and an Aetna Medicare Advantage plan.

Aetna Medicare Advantage and Original Medicare

Original Medicare Part B treats breast ultrasound as diagnostic, not screening. It is covered only when a provider documents medical necessity, such as evaluating a mass found on a mammogram, investigating signs or symptoms, or assessing an implant rupture. Routine ultrasound screening for dense breasts alone is not covered.⁵

When Medicare does cover the test, patients typically pay 20% coinsurance after meeting the Part B deductible. Aetna Medicare Advantage plans must cover at least everything Original Medicare covers, with cost sharing that varies by plan; some add benefits beyond that baseline, so check your Summary of Benefits.

Physicians in several states have reported that Medicare began denying claims for supplemental breast ultrasound screenings starting in 2023 and 2024, even when similar claims had been reimbursed before. The Centers for Medicare and Medicaid Services has said its coverage policy has not changed and that ultrasounds performed as screening rather than diagnostic tests are not covered.⁶

State Laws That Can Expand Your Coverage

Where you live matters. Several states require insurers, including Aetna, to cover breast ultrasounds more broadly than federal law does.

New York: since January 1, 2017, non-grandfathered policies issued in New York must cover diagnostic mammograms, breast ultrasounds, and breast MRIs with no deductible, copay, or coinsurance when medically necessary and performed in-network. If an insurer denies on medical necessity, patients can pursue an internal appeal and an external appeal through the state Department of Financial Services.⁷
Connecticut: coverage is required for a comprehensive breast ultrasound if a mammogram shows heterogeneous or dense breast tissue, or if the patient is at increased risk based on family history, personal history, or genetic testing. The copay cannot exceed $20.⁸
Illinois: state law provides no-cost coverage for ultrasounds and MRIs when a routine mammogram shows dense breasts and the procedure is medically necessary.⁹
Colorado: effective August 2025, diagnostic and supplemental imaging is covered without cost sharing for people with at least one risk factor, including dense breasts.¹⁰

These laws generally apply only to fully insured plans regulated by the state. Self-insured employer plans governed by ERISA, along with Medicare and Medicaid, are typically exempt.¹¹

Prior Authorization, Coding, and HDHPs

Aetna does not require prior authorization for breast ultrasound. Neither the 2025 nor the 2026 Aetna precertification list includes it; the only breast-related procedures that require precertification are cosmetic or reconstructive surgeries.¹²¹³

Billing codes still cause trouble. CPT 76641 (complete) and 76642 (limited) do not distinguish between screening and diagnostic ultrasounds, and when a claim is flagged as “screening” it can be denied or reduced. Clinical documentation that reflects a diagnostic purpose, such as evaluating a specific finding, symptom, or risk factor, tends to get through.¹⁴⁹

If you have an Aetna high-deductible health plan with an HSA, IRS Notice 2024-75 treats breast ultrasounds and MRIs for people not diagnosed with breast cancer as preventive care. The plan can cover them before you meet the deductible without affecting HSA eligibility.¹⁵

What to Do If Aetna Denies Your Claim

Denials happen even in states with strong coverage laws, often because of coding, a dispute over whether the test was screening or diagnostic, or a plan-specific exclusion. Start with your Explanation of Benefits and your Summary of Benefits and Coverage to pin down the stated reason. A call to Aetna Member Services sometimes resolves a billing or coding error on the spot.

If the denial holds, file a formal internal appeal. You have 180 days from the denial notice. Appeals can be submitted by phone or by mailing a completed complaint and appeal form, with your member ID, the denial letter, and supporting documents such as medical records and a letter of medical necessity from your physician.¹⁶

Decision timelines depend on your plan:

One-level appeal plans: 30 days for pre-service claims, 60 days for post-service claims.
Two-level appeal plans: 15 days for pre-service and 30 days for post-service at the first level. If denied, you have 60 days to request a second review.
Urgent claims where a delay could seriously harm your health: 72 hours for one-level plans, 36 hours for two-level plans.

If the internal appeal is denied, you may be eligible for an external review by an independent third party under the ACA. You generally have 60 days from the final internal decision to request it, and the reviewer must decide within 60 days.¹⁶

Patient advocates suggest not paying a denied bill right away. Work through the full appeals process, confirm the coding reflects the diagnostic basis for the ultrasound, and document every call and letter. Your state insurance department can also walk you through your rights.⁹

What the Find It Early Act Would Change

The Find It Early Act is a bipartisan bill that would require all health insurance plans, including Medicare, Medicare Advantage, Medicaid, TRICARE, and VA coverage, to cover breast ultrasounds, MRIs, and other diagnostic imaging for breast cancer with no cost sharing. It targets people at increased risk, those with dense breast tissue, and anyone a provider determines needs the imaging. The Senate version was introduced by Senator Amy Klobuchar in April 2025, and the House version was reintroduced by Representatives Rosa DeLauro and Brian Fitzpatrick in November 2025. As of mid-2026 it remains in committee and has not been enacted, so it does not change what Aetna owes you today.¹⁷¹⁸

1
Federal Register. Update to the HRSA-Supported Women’s Preventive Services Guidelines
2
WTW. Must Group Health Plans Cover Additional Breast Cancer Screenings
3
NBC Miami. Dense Breast Patients Battle to Get Coverage for Cancer Screenings
4
DenseBreast-info.org. Insurance Coverage Updates: Federal, State, Individual Insurers
5
GoodRx. Does Medicare Cover Breast Ultrasound
6
NBC News. Told to Get Extra Breast Cancer Screenings, Stuck With the Bill
7
New York DFS. Breast Cancer Screening
8
Connecticut General Assembly. Breast Cancer Screening Coverage Requirements
9
Chicago Sun-Times. Getting a Breast Ultrasound: A Matter of Life and Death
10
DenseBreast-info.org. State Law Insurance Map
11
New York State Health Department. NYS Breast Cancer FAQs
12
Aetna. 2026 Participating Provider Precertification List
13
Aetna. 2025 Participating Provider Precertification List
14
CMS. Billing and Coding: Breast Imaging
15
IRS. Notice 2024-75
16
Aetna. Claim Denials
17
U.S. Congress. S.1410 – Find It Early Act
18
Rep. DeLauro. DeLauro, Fitzpatrick, and Katie Couric Reintroduce Find It Early Act