When Medicare Covers PET Scans and When You Pay Out of Pocket

Medicare covers PET scans, but only for specific conditions and only when your doctor orders it the right way

Medicare Part B covers positron emission tomography (PET) scans for certain cancers, heart conditions, and neurological disorders — but not for screening or routine monitoring. The scan must be ordered by your doctor as medically necessary for diagnosis or treatment planning, not as a precaution. If Medicare denies the claim, you typically owe the full cost unless your doctor can show the order met coverage rules.

The conditions Medicare covers have changed over time and vary by the type of PET scan and the tracer used. Your doctor's office usually knows whether Medicare will cover the scan before you have it done, but you should ask directly rather than assume. If your condition is not on the covered list, you may still have options — some private insurance plans cover PET scans Medicare does not, or your doctor may suggest an alternative imaging test that Medicare does cover.

Key Takeaways

Medicare Part B covers PET scans for certain cancers (including lung, lymphoma, and melanoma), heart disease, and some brain disorders, but your doctor must order it as medically necessary, not for screening.
Your doctor's office should verify coverage with Medicare before the scan is scheduled, and you should ask for written confirmation of what you will owe.
If Medicare denies the claim, you are responsible for the full bill unless your doctor appeals or shows the order met Medicare's rules.
Private insurance, Medigap, or Medicare Advantage plans may cover PET scans in situations where Original Medicare does not.
PET scans typically cost $3,000 to $6,000 before insurance, so confirming coverage in advance matters financially.

Which cancers and conditions Medicare covers with PET scans

Medicare covers PET scans for diagnosis and treatment planning in several cancers: non-small cell lung cancer, lymphoma, melanoma, colorectal cancer, breast cancer, thyroid cancer, and ovarian cancer. The scan must be ordered because your doctor suspects or has diagnosed one of these cancers and needs imaging to stage it or plan treatment — not because you have a family history or are at high risk.

For heart disease, Medicare covers PET scans to assess whether heart tissue is viable (still living) after a heart attack or to evaluate whether bypass surgery or other intervention would help. For the brain, Medicare covers PET scans for dementia evaluation when Alzheimer's disease is suspected, and for some seizure disorders when surgery is being considered.

Medicare does not cover PET scans for screening — for example, scanning a healthy person to look for early cancer — or for monitoring after treatment is complete. If your doctor wants to check whether cancer has returned, Medicare may cover it if there is clinical evidence of recurrence, but routine follow-up scans are usually denied.

How to confirm Medicare will cover your PET scan before you have it

Ask your doctor's office to submit a coverage inquiry to Medicare before the scan is scheduled. The office staff can call Medicare or submit the request electronically using your diagnosis code and the reason for the scan. Medicare will respond with a coverage information — usually within a few days — telling you whether the scan is covered and what your out-of-pocket cost will be.

You should receive a written notice called an Advance Beneficiary Notice (ABN) if your doctor believes Medicare may deny the claim. The ABN tells you in advance that you may owe the full cost, and you sign it to acknowledge that you understand the risk. Do not skip this step — if you do not sign an ABN and Medicare denies the claim, you cannot be billed for the scan.

If your doctor's office says they cannot check coverage in advance, ask to speak with the billing department directly. Most imaging centers and hospitals can verify coverage by phone in under an hour. If they refuse, you can call Medicare yourself at 1-800-MEDICARE and provide your claim number and diagnosis code.

What you will pay if Medicare covers the scan

If Medicare covers your PET scan, you pay your Part B deductible (if you have not met it for the year) plus 20 percent of the Medicare-approved amount. The Medicare-approved amount varies by location and imaging center, but typically ranges from $2,500 to $4,000. That means your 20 percent coinsurance is usually $500 to $800.

If you have a Medigap policy (supplemental insurance), it may cover some or all of your coinsurance. If you have a Medicare Advantage plan, your out-of-pocket cost depends on your plan's rules — some charge a copay instead of coinsurance, and some waive the cost entirely if the scan is in-network.

The imaging center or hospital should tell you your estimated out-of-pocket cost before the scan. Ask for this in writing so you have a record if the final bill differs.

What happens if Medicare denies your PET scan

If Medicare denies the claim, the imaging center will send you a notice called a Remittance information explaining why. Common reasons for denial are: the diagnosis code does not match a covered condition, the scan was ordered for screening rather than diagnosis, or the medical record did not show sufficient evidence that the scan was necessary.

You have the right to request that Medicare reconsider the denial. Your doctor can file an appeal on your behalf, usually by submitting additional medical records or a letter explaining why the scan was medically necessary. This process is called a redetermination and must be requested within 120 days of the denial notice.

If you do not appeal and Medicare does not cover the scan, you are responsible for the full bill — typically $3,000 to $6,000. Some imaging centers will negotiate a lower cash price if you pay out of pocket, so it is worth asking.

Private insurance and Medicare Advantage alternatives

If you have a Medicare Advantage plan (Part C) instead of Original Medicare, your coverage for PET scans may be different. Some Medicare Advantage plans cover PET scans for conditions that Original Medicare does not, or they may have lower out-of-pocket costs. Check your plan's coverage documents or call the plan directly before scheduling.

If you have both Original Medicare and a Medigap policy, the Medigap plan may cover the 20 percent coinsurance, reducing your cost to zero after you meet your Part B deductible. If you have retiree health insurance from a former employer, that plan may also cover PET scans; check your plan documents or call the benefits line.

If you are uninsured or underinsured, ask the imaging center about financial information programs or payment plans. Some hospitals offer reduced rates based on income, and some imaging centers offer cash discounts if you pay upfront.

When your doctor might order an alternative to a PET scan

If Medicare will not cover a PET scan for your condition, your doctor may suggest a CT scan, MRI, or other imaging test instead. These alternatives are often covered by Medicare and may provide similar information, depending on what your doctor is looking for. A CT scan is faster and cheaper than a PET scan, though it may be less sensitive for certain cancers.

Talk with your doctor about whether an alternative test would answer the same clinical question. If your doctor believes a PET scan is necessary and Medicare will not cover it, ask whether they can reorder it with different wording or additional clinical evidence that might change Medicare's decision.

Frequently Asked Questions

Can I get a PET scan for cancer screening if I have a family history?

No. Medicare does not cover PET scans for screening, even if you have a strong family history of cancer or genetic risk factors. The scan must be ordered because your doctor suspects or has diagnosed cancer based on symptoms or other test results. If you are concerned about cancer risk, talk with your doctor about screening options that Medicare does cover, such as mammography or colonoscopy.

What if my doctor says the PET scan is urgent and cannot wait for Medicare to verify coverage?

Your doctor can order the scan when ready and submit the coverage verification to Medicare afterward. However, you should still ask for an Advance Beneficiary Notice so you understand your financial risk. If Medicare later denies the claim, you can appeal, and your doctor can provide documentation of the urgency to support the appeal.

Will Medicare cover a PET scan if I have already had one for the same condition?

It depends on the reason for the second scan. Medicare may cover a repeat PET scan if your condition has changed or if your doctor is reassessing treatment options. Medicare typically does not cover routine follow-up scans after treatment is complete. Your doctor's office should verify coverage before scheduling a repeat scan.

Do I need to go to a specific imaging center for Medicare to cover the PET scan?

No, but the imaging center must be enrolled in Medicare. Most hospitals and large imaging centers are enrolled. Ask your doctor's office whether the center they are referring you to accepts Medicare. If you go to a non-enrolled center, Medicare will not cover the scan and you will owe the full cost.

What is the difference between a PET scan and a PET-CT scan, and does Medicare cover both?

A PET-CT scan combines PET imaging with a CT scan in one procedure, giving your doctor both metabolic and structural information. Medicare covers PET-CT scans under the same rules as PET scans alone — for the same conditions and with the same coverage requirements. PET-CT scans typically cost more than PET scans alone, but your out-of-pocket cost follows the same 20 percent coinsurance rule.

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.