What Medicare Covers for PET Scans

Medicare covers PET scans, but only for specific conditions and only when your doctor orders it as medically necessary

A PET scan (positron emission tomography) is an imaging test that uses a radioactive tracer to show how organs and tissues are working. Medicare Part B covers the cost of a PET scan when it meets two conditions: your doctor must order it for one of the conditions Medicare recognizes, and the scan must be performed at a facility that is Medicare-approved.

The conditions Medicare covers PET scans for are cancer (including initial staging, restaging, and monitoring), dementia (to distinguish Alzheimer's disease from other types), and cardiac viability (to see if heart tissue can recover after a heart attack). If your doctor orders a PET scan for a condition not on this list, Medicare will not cover it, and you will owe the full cost.

Your out-of-pocket cost depends on whether you have met your Part B deductible for the year and whether you have supplemental coverage. After you meet the deductible, Medicare pays 80 percent of the approved amount, and you pay 20 percent. The approved amount varies by location and facility.

Key Takeaways

Medicare Part B covers PET scans only for cancer, dementia, or cardiac viability when ordered by your doctor.
The scan must be done at a Medicare-approved facility, or Medicare will not pay for it.
You pay 20 percent of the approved cost after you meet your Part B deductible; the exact amount depends on your location.
If your doctor orders a PET scan for any other reason, you will owe the entire bill unless you have a supplemental plan that covers it.

Which conditions Medicare will pay for

Medicare covers PET scans for cancer in several ways. If you have been diagnosed with cancer, Medicare covers a PET scan to stage the cancer (determine how far it has spread) before treatment begins. It also covers PET scans to restage cancer if your doctor suspects it has returned or spread after treatment. For some cancers, Medicare covers a follow-up PET scan to monitor whether treatment is working.

For dementia, Medicare covers a PET scan when your doctor is trying to determine whether you have Alzheimer's disease or a different type of dementia. The scan helps distinguish between conditions that look similar on other tests but need different treatments. Medicare does not cover PET scans for dementia screening in people without symptoms.

For cardiac viability, Medicare covers a PET scan when your doctor is evaluating whether your heart muscle can recover function after a heart attack or whether you are a candidate for bypass surgery or angioplasty. This scan shows which parts of your heart are still viable (able to work again) and which are permanently damaged.

How to make sure Medicare will pay

Before your PET scan is scheduled, ask your doctor whether the scan is for one of the three conditions Medicare covers. Your doctor should know this, but it is worth confirming because if the scan is ordered for a different reason, you will be responsible for the cost.

Confirm that the facility where the scan will be performed is Medicare-approved. You can ask the facility directly, or you can call Medicare at 1-800-MEDICARE. If the facility is not approved, Medicare will deny the claim even if the scan is for a covered condition.

Ask your doctor's office to submit the order to Medicare for a coverage information before the scan is scheduled. This is called a prior authorization. Medicare will review the order and tell you in writing whether it will cover the scan. This step takes a few days but prevents surprises after the scan is done.

What you will pay out of pocket

Your cost for a PET scan depends on three things: whether you have met your Part B deductible, whether you have a Medigap or Medicare Advantage plan, and the approved amount in your area.

If you have not met your Part B deductible for the year, you pay the full deductible amount first. For 2024, the Part B deductible is $240, but this amount changes each year. Once you meet the deductible, Medicare pays 80 percent of the approved amount, and you pay 20 percent.

The approved amount is set by Medicare and varies by location and facility. A PET scan typically costs between $3,000 and $6,000 before insurance, but the approved amount is usually lower. Your 20 percent share will be somewhere in that range depending on where you live.

If you have a Medigap plan (supplemental insurance), it may cover your 20 percent coinsurance, which would reduce your out-of-pocket cost to zero or close to it. If you have a Medicare Advantage plan, your cost depends on your plan's rules — some plans cover the full cost after a copay, and others explore coinsurance. Check your plan documents or call your plan to find out what you will owe.

What happens if Medicare denies the claim

If Medicare denies your PET scan claim, you have the right to appeal. You will receive a notice called an Explanation of Benefits that explains why the claim was denied. Common reasons include the scan was not ordered for a covered condition, the facility was not Medicare-approved, or the doctor did not submit a prior authorization.

To appeal, you can contact Medicare at 1-800-MEDICARE or submit a written appeal to the address on your Explanation of Benefits. You have 120 days from the date on the notice to file an appeal. If you believe the denial was wrong — for example, if your doctor ordered the scan for cancer but Medicare says it was not for a covered condition — include a letter from your doctor explaining why the scan was medically necessary.

If you cannot afford to pay the bill while your appeal is being reviewed, ask the facility whether it will hold the bill. Some facilities will not pursue collection while an appeal is pending.

PET scans versus other imaging tests

Your doctor may recommend a PET scan, a CT scan, an MRI, or another imaging test depending on what they are looking for. Medicare covers all of these tests when they are medically necessary, but the coverage rules are slightly different for each one.

A CT scan uses X-rays to create detailed images of organs and is faster and less expensive than a PET scan. Medicare covers CT scans for many more conditions than PET scans. An MRI uses magnetic fields instead of radiation and is often used to look at soft tissue like the brain or spinal cord. Medicare covers MRI for a wide range of conditions.

A PET scan is unique because it shows how tissue is functioning, not just what it looks like. This makes it especially useful for cancer and dementia. If your doctor recommends a PET scan instead of a CT or MRI, ask why — understanding the reason will help you know whether Medicare is likely to cover it.

Frequently Asked Questions

What if my doctor orders a PET scan but Medicare says it is not covered?

You can ask your doctor to submit additional information explaining why the scan is medically necessary for your condition. You can also file an appeal with Medicare within 120 days of receiving the denial notice. If you disagree with the appeal decision, you have the right to request a hearing before an administrative law judge.

Do I need a referral from my primary care doctor to get a PET scan?

Medicare Part B does not require a referral, but your doctor does need to order the scan. If you see a specialist, that specialist can order it. Some Medicare Advantage plans do require a referral — check your plan documents or call your plan to find out.

Can I get a PET scan at an urgent care or imaging center, or does it have to be at a hospital?

A PET scan can be done at a hospital, imaging center, or outpatient facility as long as it is Medicare-approved. Ask your doctor where they plan to send you, and confirm that the facility accepts Medicare before the scan is scheduled.

Will Medicare cover a PET scan if I have already had a CT scan or MRI?

Yes, if your doctor determines that a PET scan is medically necessary even though you have had other imaging tests. Medicare will cover it as long as it is for one of the three covered conditions. Your doctor should document in your medical record why the additional scan is needed.

What if I have a Medicare Advantage plan instead of Original Medicare?

Medicare Advantage plans must cover the same PET scans that Original Medicare covers, but your out-of-pocket cost may be different. Some plans cover the full cost after a copay, while others explore coinsurance. Call your plan to find out what you will owe before the scan is scheduled.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.