Does Medicare Cover a Bone Density Test?

Understanding Bone Density Tests and Medicare Coverage

A bone density test, often referred to as a DEXA scan, is a specialized imaging procedure that uses X-rays to measure the amount of minerals, such as calcium, in your bones. This test plays a significant role in assessing bone strength and identifying potential issues like osteoporosis, a condition characterized by weakened bones. By measuring bone mineral density, healthcare providers can diagnose osteoporosis before a fracture occurs, estimate an individual’s risk of breaking a bone, and monitor the effectiveness of treatments for bone loss.

Original Medicare Part B Coverage

Medicare Part B, which covers outpatient medical services, covers bone density tests under specific conditions. The test must be deemed medically necessary by a physician. This medical necessity is typically established for individuals at risk of osteoporosis or those needing monitoring for treatment effectiveness.

Part B covers bone density tests for beneficiaries who meet eligibility criteria, including:
Women determined to be estrogen-deficient and at risk for osteoporosis.
Individuals whose X-rays indicate possible osteoporosis, osteopenia, or vertebral fractures.
Those taking or planning to take steroid-type medications known to affect bone health, such as prednisone.
Individuals diagnosed with primary hyperparathyroidism.
Individuals being monitored to assess whether their osteoporosis drug therapy is effective.

Medicare Part B covers a bone density test once every 24 months for preventive screening when these specific criteria are met. However, if a healthcare provider determines that more frequent testing is medically necessary due to a patient’s condition or treatment plan, Medicare may cover additional tests. For covered bone density tests, the Part B deductible applies, and then you pay 20% of the Medicare-approved amount as coinsurance. If the facility and physician performing the test accept Medicare assignment, the test may be covered at 100% of the Medicare-approved amount, meaning no out-of-pocket costs for the test itself.

How Medicare Advantage and Supplemental Plans Affect Coverage

Medicare Advantage Plans (Part C) are offered by private companies and must cover everything Original Medicare Parts A and B cover, including bone density tests. These plans may have different cost-sharing structures, such as varying copayments, deductibles, or out-of-pocket maximums. Many of these plans also operate with network restrictions, requiring beneficiaries to use in-network providers for covered services to receive the highest level of benefits.

Medicare Supplement Insurance Plans (Medigap plans) help cover out-of-pocket costs associated with Original Medicare. If Original Medicare Part B covers a bone density test, a Medigap policy can help pay for the remaining expenses, such as the Part B deductible and the 20% coinsurance. This means that for services covered by Original Medicare, a Medigap plan can significantly reduce or even eliminate your out-of-pocket costs for bone density tests. Medigap plans allow you to see any healthcare provider in the United States who accepts Medicare, without needing referrals to specialists.

Practical Steps for Coverage and Cost Management

Before undergoing a bone density test, discuss the medical necessity of the procedure with your doctor. Your doctor’s office can assist in confirming Medicare coverage details and checking for any prior authorization requirements. If there is uncertainty about Medicare covering a specific service, ask your provider for an Advance Beneficiary Notice of Noncoverage (ABN). An ABN is a form that informs you that Medicare may not pay for a service and that you might be responsible for the cost.

During the visit, ensure that the facility performing the bone density test accepts Medicare assignment to minimize potential out-of-pocket expenses. After receiving the service, review the statements you receive from Medicare or your plan. If you have Original Medicare, you will receive a Medicare Summary Notice (MSN) every few months, detailing the services you received, what Medicare paid, and any amount you might owe.

If you are enrolled in a Medicare Advantage Plan, you will typically receive an Explanation of Benefits (EOB) from your private insurer, which provides similar information about billed services and payments. Reviewing these documents carefully helps ensure that all services are accurately billed and covered. If you notice any discrepancies or unexpected charges, contact your healthcare provider’s billing department, your Medicare Advantage plan, or Medicare directly for clarification.