Does Medicare Cover Bone Density Tests?

Bone density tests, often referred to as bone mass measurements or DEXA scans, are important tools for evaluating bone health. These tests help identify individuals at risk for osteoporosis, a condition that can lead to fragile bones and increased fracture risk. Medicare does provide coverage for bone density tests under specific circumstances, recognizing their role in preventive care and managing bone-related conditions.

Medicare Part B Coverage for Bone Density Tests

Medicare Part B covers bone density tests when certain medical criteria are met, typically for preventive screening. A doctor must order the test, confirming its medical necessity for the beneficiary. The most common type of bone density test covered is the Dual-energy X-ray Absorptiometry (DEXA) scan, which measures bone density in areas like the spine and hip.

Coverage is generally provided once every 24 months. However, Medicare may cover these tests more frequently if a medical reason warrants it. This increased frequency requires a doctor’s documentation of medical necessity.

Several specific conditions and risk factors qualify an individual for Medicare Part B coverage of bone density tests. These include:
Women determined by their doctor to be estrogen-deficient and at clinical risk for osteoporosis based on medical history.
Individuals with vertebral abnormalities shown by X-rays, indicative of osteoporosis, osteopenia, or vertebral fractures.
Those on long-term glucocorticoid (steroid) therapy, equivalent to 5.0 mg of prednisone or more per day for over three months.
Individuals diagnosed with primary hyperparathyroidism.
Patients being monitored to assess the response to FDA-approved osteoporosis drug therapy.

The test must be performed by a qualified provider and facility that accepts Medicare assignment.

Understanding Costs for Bone Density Tests

When a bone density test is covered by Original Medicare (Part B), specific out-of-pocket costs may apply. Generally, if the test meets the established criteria and is considered a preventive service, beneficiaries typically pay nothing for the test. This means the Part B deductible and coinsurance are waived when the service is provided by a facility that accepts Medicare assignment.

However, if the test is not considered a preventive service or if additional diagnostic services are performed during the same visit, standard Part B cost-sharing rules might apply. For covered services under Part B, after meeting the annual deductible, beneficiaries are typically responsible for a 20% coinsurance of the Medicare-approved amount. The Medicare-approved amount is the fee that Medicare has agreed to pay for a particular service, and providers who accept Medicare assignment agree to accept this amount as full payment.

If a doctor recommends services more often than Medicare covers, or services that Medicare does not cover, the beneficiary may be responsible for some or all of those additional costs. It is always advisable to discuss potential costs with the doctor and testing facility before the service to understand any financial obligations. Understanding these cost structures helps beneficiaries plan for their healthcare expenses.

Medicare Advantage and Supplement Plans

Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare and must cover at least the same services as Original Medicare (Parts A and B). This includes coverage for bone density tests if they meet the same medical necessity criteria as Original Medicare. While Advantage plans provide the same level of coverage, they may have different cost-sharing structures, network restrictions, and requirements for prior authorization.

Beneficiaries enrolled in a Medicare Advantage plan should consult their specific plan’s benefits documentation or contact the plan administrator to understand any copayments, deductibles, or network rules. These plans often have specific provider networks, and receiving care outside the network could result in higher out-of-pocket costs or no coverage at all.

Medicare Supplement (Medigap) plans work differently; they do not provide additional coverage beyond what Original Medicare covers. Instead, Medigap plans help pay for some of the out-of-pocket costs associated with Original Medicare, such as deductibles, coinsurance, and copayments. If Original Medicare covers a bone density test, a Medigap policy can help reduce the beneficiary’s share. These plans do not impose network restrictions, allowing beneficiaries to see any provider who accepts Medicare.

Steps to Get Your Test Covered

First, obtain a doctor’s order for the bone density test. The order must state medical necessity, aligning with Medicare’s coverage criteria.

Next, confirm the provider and facility accept Medicare assignment. Verify their participation beforehand.

Discuss medical necessity and potential coverage with your doctor and the testing facility’s billing department before the test. Maintain accurate medical records supporting the test’s need.

After the test, review your Medicare Summary Notice (MSN). The MSN details services billed, Medicare payments, and amounts owed. If denied, the MSN provides appeal instructions.