Does Medicare Cover an MRI of the Knee?
Unravel Medicare's coverage for essential medical imaging. Understand your benefits, potential costs, and how to get the care you need.
Medicare is a federal health insurance program that provides coverage for millions of Americans, primarily those aged 65 or older, and certain younger individuals with disabilities. This program helps eligible beneficiaries manage a wide range of healthcare expenses. Its design aims to make medically necessary services accessible to a broad population, contributing to overall health and financial security.
Original Medicare Coverage for Knee MRIs
Original Medicare covers medically necessary diagnostic tests, including magnetic resonance imaging (MRI) of the knee. An MRI of the knee is covered under Medicare Part B, which is medical insurance. This coverage applies when the procedure is performed on an outpatient basis, such as in a doctor’s office, an outpatient clinic, or a hospital outpatient department.
For a knee MRI to be covered, it must be ordered by a physician who accepts Medicare assignment. The test must also be deemed medically necessary for the diagnosis or treatment of a specific medical condition. This could include persistent knee pain, an injury, or suspected structural damage to the knee. Medically necessary services are those required to diagnose or treat an illness, injury, condition, or its symptoms, meeting accepted standards of medicine.
If a knee MRI is performed during an inpatient hospital stay, its costs fall under Medicare Part A, which is hospital insurance. However, most knee MRIs are conducted in an outpatient setting, making Part B the primary coverage source for these procedures.
Understanding Your Out-of-Pocket Costs
When a knee MRI is covered under Original Medicare Part B, beneficiaries are responsible for out-of-pocket costs. Individuals must meet the annual Part B deductible before Medicare begins to pay its share. For 2025, this deductible is $257.
After the deductible has been satisfied, beneficiaries pay a coinsurance amount. This is 20% of the Medicare-approved amount for the MRI. For instance, if the Medicare-approved amount for the MRI is $1,000, and the deductible has been met, the beneficiary would pay $200.
Doctors and facilities are required to accept Medicare assignment. If a provider does not accept assignment, they might charge more than the Medicare-approved amount, leading to excess charges for the beneficiary. Supplementary insurance plans, such as Medigap, can help cover these out-of-pocket expenses, including deductibles and coinsurance.
Medicare Advantage Plan Coverage
Medicare Advantage plans, also known as Part C, are offered by private insurance companies. These plans are required by law to cover at least all services Original Medicare covers. This includes medically necessary knee MRIs, ensuring beneficiaries receive the same baseline coverage regardless of their plan choice.
However, Medicare Advantage plans often administer coverage differently and may have varying cost-sharing structures. Beneficiaries might encounter different deductibles, copayments, or coinsurance amounts for an MRI compared to Original Medicare. Many plans also operate with provider networks, which means the MRI facility must be within the plan’s network for coverage or to receive lower costs.
A notable difference with Medicare Advantage plans is the requirement for prior authorization or a referral from a primary care physician before an MRI can be performed. This process ensures the service is medically necessary according to the plan’s criteria. Individuals enrolled in a Medicare Advantage plan should consult their specific plan’s Summary of Benefits or contact the plan directly to understand their coverage, costs, and procedural requirements for a knee MRI.