Does Medicare Cover a Nuclear Stress Test?

A nuclear stress test is a diagnostic imaging procedure used to assess heart health, particularly blood flow to the heart muscle. It involves injecting a small amount of radioactive tracer into the bloodstream, followed by imaging with a special camera, both at rest and after the heart is stressed, either through exercise or medication. This test helps healthcare providers identify areas of the heart that may not be receiving adequate blood supply, which can indicate conditions such as coronary artery disease.

Medicare Coverage for Nuclear Stress Tests

Medicare generally provides coverage for nuclear stress tests when they are deemed medically necessary. These diagnostic tests typically fall under Medicare Part B, which is the medical insurance component of Original Medicare. Part B helps cover a range of outpatient services, including doctor visits, preventive services, certain medical equipment, and various diagnostic tests. This coverage ensures that beneficiaries can access advanced imaging to evaluate their cardiac health.

Meeting Coverage Requirements

For a nuclear stress test to be covered by Medicare, it must meet specific requirements, primarily demonstrating medical necessity. This means a physician must determine that the test is needed for the diagnosis or treatment of a medical condition. For example, if a patient presents with symptoms such as chest pain or shortness of breath, or has a history of heart disease, a doctor might order this test to investigate the cause of these symptoms or monitor an existing condition.

The test must be ordered by a licensed physician who believes it is appropriate for the patient’s condition. Furthermore, the nuclear stress test must be performed in a facility that is approved by Medicare. These facilities adhere to specific standards to ensure the quality and safety of the diagnostic procedures they provide.

Understanding Patient Costs

Under Original Medicare, beneficiaries typically incur certain out-of-pocket costs for services covered by Part B, including nuclear stress tests. Before Medicare begins to pay its share, individuals must first meet the annual Part B deductible. For 2025, this deductible is $257.

After the deductible has been met, Medicare generally pays 80% of the Medicare-approved amount for the covered service. The beneficiary is then responsible for the remaining 20% coinsurance. It is also important to choose a healthcare provider who accepts “Medicare assignment,” meaning they agree to accept the Medicare-approved amount as full payment for their services. Providers who accept assignment cannot bill you for more than the Medicare deductible and coinsurance, which helps limit your out-of-pocket expenses.

Impact of Other Medicare Plans

Beyond Original Medicare, beneficiaries may have other types of coverage that influence the cost and process for obtaining a nuclear stress test. Medicare Advantage Plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must cover at least the same services as Original Medicare, including nuclear stress tests, but they often have different cost-sharing structures, such as copayments instead of coinsurance. Medicare Advantage Plans may also require referrals from a primary care physician or prior authorization before certain procedures, like a nuclear stress test, can be performed.

Medigap policies, or Medicare Supplement Insurance, are another option available to beneficiaries with Original Medicare. These policies are sold by private companies and help pay for some of the out-of-pocket costs that Original Medicare does not cover, such as the Part B deductible and coinsurance.