Medicare's coverage of PET scans depends on what condition your doctor is investigating

Medicare Part B covers PET (positron emission tomography) scans, but only for specific conditions. Your doctor must order the scan to diagnose or monitor one of the conditions Medicare recognizes. If the scan is for a condition not on that list, Medicare will not pay for it, and you may owe the full cost.

The conditions Medicare covers PET scans for include certain cancers, heart disease, and some neurological conditions like dementia. Your doctor knows whether your condition qualifies. If you are unsure, you can ask your doctor directly or call Medicare at 1-800-MEDICARE before the scan to confirm coverage.

Key Takeaways

  • Medicare Part B covers PET scans only when ordered to diagnose or monitor specific conditions, primarily certain cancers, coronary artery disease, and some forms of dementia.
  • Your doctor must document that the scan is medically necessary for one of Medicare's covered conditions, or Medicare will deny the claim.
  • You pay 20 percent of the approved amount after you meet your Part B deductible, unless you have supplemental coverage.
  • Calling Medicare before your scan can confirm whether your specific situation qualifies for coverage and prevent unexpected bills.

Which conditions may have access to for Medicare-covered PET scans

Medicare covers PET scans for cancer diagnosis and monitoring. This includes initial diagnosis of certain cancers, checking whether cancer has spread, and monitoring for recurrence after treatment. The cancers covered are lung cancer, breast cancer, colorectal cancer, lymphoma, melanoma, and some others. Your oncologist will know whether your cancer type qualifies.

Medicare also covers PET scans for coronary artery disease when your cardiologist needs to assess blood flow to your heart muscle. The scan helps determine whether you need a stent or bypass surgery. This is different from a stress test and is ordered when other tests have not given a clear answer.

For neurological conditions, Medicare covers PET scans to evaluate dementia, particularly to distinguish Alzheimer's disease from other types of dementia. Your neurologist or primary care doctor must order the scan as part of the diagnostic workup.

If your doctor is ordering a PET scan for a condition not listed here — such as infection, inflammation, or a psychiatric condition — Medicare will likely deny coverage. Ask your doctor whether your condition is on Medicare's covered list before scheduling.

What you pay out of pocket

If Medicare covers your PET scan, you pay 20 percent of the approved amount after you have met your Part B deductible for the year. The approved amount is what Medicare decides the scan is worth, not what the imaging center charges. The center bills Medicare directly, and Medicare pays its 80 percent share to the center.

Your actual out-of-pocket cost depends on whether you have already met your deductible and whether you have supplemental insurance. If you have not met your deductible, you pay the full deductible first, then 20 percent of the approved amount. If you have a Medigap or Medicare Advantage plan, that plan may cover some or all of your 20 percent share.

Ask the imaging center for an estimate before your scan. They can tell you what Medicare's approved amount is for your scan and calculate your expected cost based on your deductible status. This prevents surprises at billing time.

How to confirm coverage before your scan

The safest step is to call Medicare at 1-800-MEDICARE before your scan is scheduled. Have your doctor's name, the reason for the scan, and your Medicare number ready. Medicare can tell you in one call whether your specific situation qualifies for coverage.

You can also ask your doctor's office to check coverage. Many offices do this routinely before ordering imaging. They submit your diagnosis code and the scan type to Medicare and receive a coverage information within a few days. This is called a prior authorization or pre-authorization, though Medicare does not always require it for PET scans.

If Medicare denies coverage, you have the right to appeal. Your doctor can provide additional medical records or documentation to support the medical necessity of the scan. The appeal process takes several weeks, so discuss timing with your doctor if you need the scan urgently.

PET scans ordered by non-Medicare providers

If you receive care at a Veterans Affairs facility, a military hospital, or an Indian Health Service clinic, Medicare does not pay. Those systems have their own coverage rules. Ask your provider directly whether they cover PET scans for your condition.

If you are in a Medicare Advantage plan, your plan may have different coverage rules than Original Medicare. Some Advantage plans cover PET scans for additional conditions beyond what Original Medicare covers. Check your plan documents or call your plan's customer service number to confirm.

What happens if Medicare denies your claim

If the imaging center bills Medicare and Medicare denies the claim, the center must send you a notice explaining why. The notice will say whether the denial is because your condition does not may have access to, because the scan was not medically necessary, or for another reason.

You are not responsible for the full bill while you appeal, as long as you did not sign an agreement beforehand saying you would pay if Medicare denied it. If you did sign such an agreement (called an Advance Beneficiary Notice), you may owe the bill if the appeal fails.

To appeal, follow the instructions on the denial notice. You have 120 days from the date of the notice to file. Your doctor can help by submitting additional medical records that show why the scan was necessary.

Medicare Advantage and PET scan coverage

If you have a Medicare Advantage plan, your plan pays for PET scans instead of Original Medicare. Advantage plans must cover at least what Original Medicare covers, but many cover more. Some Advantage plans cover PET scans for conditions that Original Medicare does not, such as certain infections or inflammatory conditions.

Check your plan's formulary or coverage document, which lists what services are covered. You can also call your plan's customer service number and ask whether PET scans are covered for your specific diagnosis. Your out-of-pocket cost may be different from Original Medicare — some Advantage plans charge a copay instead of 20 percent coinsurance.

Frequently Asked Questions

Will Medicare pay for a PET scan if my doctor thinks I might have cancer but hasn't confirmed it yet?

Yes, Medicare covers PET scans for initial cancer diagnosis. Your doctor does not need to have already confirmed cancer — the scan is often used to diagnose it. The scan must be ordered by your doctor as part of the diagnostic workup, not as a screening test for someone with no symptoms.

What if I have a PET scan and then find out Medicare doesn't cover it?

If you signed an Advance Beneficiary Notice before the scan, you may owe the bill. If you did not sign one, the imaging center cannot bill you while you appeal. Ask the center for a copy of any notice you signed before the scan. If you did not sign anything, tell the center you want to appeal the denial before paying.

Does Medicare cover PET scans for screening if I have no symptoms?

No. Medicare covers PET scans only when your doctor orders them to diagnose or monitor a specific condition. Screening scans for people with no symptoms or signs of disease are not covered, even for high-risk individuals.

Can I get a second opinion on whether Medicare will cover my PET scan?

Yes. You can call Medicare at 1-800-MEDICARE and ask about your specific situation. You can also ask your doctor to submit a prior authorization request, which gives you a written coverage information before the scan is done. This takes a few days but prevents billing surprises.

If I have both Medicare and a Medigap plan, who pays for the PET scan?

Medicare pays its 80 percent share first. Your Medigap plan then pays some or all of your 20 percent coinsurance, depending on which Medigap plan you have. Ask your Medigap plan which letter plan you have — plans G, N, and others have different coverage levels for coinsurance.