Does Medicare Cover an Echocardiogram?

An echocardiogram is a common diagnostic test used to evaluate heart health, and understanding how Medicare covers this procedure is important for beneficiaries. This article clarifies the circumstances under which Medicare covers echocardiograms, patient costs, and how to navigate potential coverage issues.

Understanding Echocardiograms and Medicare Coverage Principles

An echocardiogram is a non-invasive diagnostic test that uses sound waves to create live images of the heart. It allows healthcare providers to visualize the heart’s structure, assess its function, and observe blood flow through its chambers and valves. It can help diagnose various heart conditions, such as heart muscle diseases, valve abnormalities, or fluid accumulation around the heart. Healthcare providers commonly order an echocardiogram to investigate symptoms like chest pain, shortness of breath, or irregular heartbeats.

Medicare covers diagnostic tests, including echocardiograms, when they are considered medically necessary. Medical necessity means the service is appropriate for diagnosing or treating an illness, injury, or medical condition, adhering to generally accepted standards of medical practice. The provider performing the test must also accept Medicare assignment.

Medicare Part Coverage Specifics

Medicare coverage for an echocardiogram depends on whether the test is performed in an inpatient or outpatient setting and which part of Medicare is active. Outpatient echocardiograms are covered under Medicare Part B (Medical Insurance). Part B covers a range of outpatient services, including doctor’s services, clinical laboratory tests, and other diagnostic procedures. If a healthcare professional recommends an echocardiogram during a “Welcome to Medicare” preventive visit, Part B may cover it as well.

If an echocardiogram is performed during a covered inpatient hospital stay, Medicare Part A (Hospital Insurance) covers the test as part of the overall inpatient services. Part A covers hospital stays, skilled nursing facility care, and certain home health services.

Medicare Advantage Plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare. These plans are required to cover at least the same services as Original Medicare (Parts A and B), which includes medically necessary echocardiograms. However, Medicare Advantage plans may have different rules, such as requiring beneficiaries to use in-network providers or obtaining prior authorization for certain services.

Your Costs and Financial Responsibility

Under Original Medicare Part B, beneficiaries have out-of-pocket costs for an echocardiogram, even when it is medically necessary. After meeting the annual Part B deductible ($257 in 2025), beneficiaries are responsible for a 20% coinsurance of the Medicare-approved amount for the test. For example, if the Medicare-approved amount for an echocardiogram is $1,000 and the deductible has been met, Medicare would pay $800, and the beneficiary would owe $200.

Costs can differ for individuals enrolled in Medicare Advantage plans. These plans may charge copayments instead of coinsurance for diagnostic tests, and the specific amounts can vary significantly. Medicare Advantage plans also have an annual out-of-pocket maximum, providing a limit on how much a beneficiary must pay for covered services in a year.

Supplemental insurance, such as a Medigap policy, can help cover some or all of the out-of-pocket costs associated with Original Medicare. Medigap plans can help pay for the Part A and B deductibles, coinsurance, and copayments, reducing a beneficiary’s financial responsibility for services like echocardiograms. If a healthcare provider does not accept Medicare assignment, they may charge more than the Medicare-approved amount, which could result in additional costs for the beneficiary.

Navigating Coverage and Potential Denials

Receiving a doctor’s order that clearly states the medical necessity for an echocardiogram is a foundational step for Medicare coverage. Without a proper order, coverage may be denied, leaving the beneficiary responsible for the full cost.

An Advance Beneficiary Notice of Noncoverage (ABN) is a document a provider gives to an Original Medicare beneficiary before providing a service if the provider believes Medicare might not cover it. When presented with an ABN, the beneficiary has options: accept financial responsibility if Medicare denies payment, choose not to receive the service, or request the service anyway and appeal Medicare’s decision if denied. Signing the ABN indicates an understanding that the beneficiary may be financially responsible.

Some Medicare Advantage plans may require prior authorization for certain diagnostic tests, including echocardiograms, before the service is rendered. Beneficiaries should always check with their Medicare Advantage plan or provider to determine if prior authorization is needed to avoid unexpected costs.

If Medicare denies coverage for an echocardiogram, beneficiaries have the right to appeal the decision. The Medicare appeal process involves five levels of review. To initiate an appeal, beneficiaries need to gather information from their healthcare provider, such as medical records and a letter of support explaining the medical necessity of the test. The initial appeal, called a redetermination, is reviewed by a Medicare administrative contractor. If the appeal is denied at one level, beneficiaries can proceed to the next level of review.