Does Medicare Cover a Bone Marrow Biopsy?

A bone marrow biopsy is a diagnostic procedure that involves taking a small sample of bone marrow for examination, often to diagnose blood disorders, infections, or certain cancers like leukemia. This test helps healthcare providers understand the health of blood cells and identify or monitor various conditions. Medicare generally covers medically necessary bone marrow biopsies. However, specific conditions and potential out-of-pocket costs apply to beneficiaries.

Medicare Part B Coverage

Medicare Part B provides coverage for bone marrow biopsies when they are medically necessary. This means a doctor must order the procedure to diagnose or treat a health condition. The biopsy must be performed by a healthcare provider who accepts Medicare assignment and takes place in a Medicare-approved setting, such as an outpatient hospital department or a doctor’s office. Coverage includes the procedure itself, professional fees for the doctor, and pathology services to analyze the sample.

Patient Cost-Sharing

Beneficiaries with Original Medicare will have out-of-pocket costs for a covered bone marrow biopsy. The annual Medicare Part B deductible must be met before Medicare pays its share. For 2025, this deductible is $257. After the deductible is met, Medicare typically pays 80% of the Medicare-approved amount for the service, with the beneficiary responsible for the remaining 20% coinsurance. These costs apply to both physician fees and facility fees for the outpatient setting.

Medicare Plan Variations

Coverage and costs for a bone marrow biopsy can vary for beneficiaries enrolled in different Medicare plans beyond Original Medicare. Medicare Advantage Plans (Medicare Part C) are offered by private insurance companies and must cover at least the same services as Original Medicare, including medically necessary bone marrow biopsies. However, these plans may have different cost-sharing structures, such as varying copayments, coinsurance, or deductibles. They might also require prior authorization or the use of in-network providers. Beneficiaries should consult their specific plan documents for detailed information on financial responsibilities and network requirements.

Medigap policies (Medicare Supplement Insurance) help cover some of the out-of-pocket costs left by Original Medicare. If a bone marrow biopsy is covered by Original Medicare, a Medigap plan can help pay for the Part B deductible and the 20% coinsurance amount. The extent of coverage depends on the specific Medigap plan purchased, as different plans offer varying levels of benefits. Medigap plans work in conjunction with Original Medicare, reducing the financial burden for services covered by Parts A and B.