Does Medicare Cover MRI Scans? Requirements & Costs

Understanding Medicare coverage for Magnetic Resonance Imaging (MRI) scans helps beneficiaries anticipate costs and make informed decisions about their medical care.

Medicare Parts and MRI Coverage

Medicare is divided into several parts, with MRI scans typically falling under Part A or Part B depending on the setting. Part A, Hospital Insurance, covers inpatient hospital stays. If an MRI occurs during an inpatient hospital admission, Part A covers the procedure as part of overall hospitalization costs.

Medicare Part B, Medical Insurance, covers outpatient services, including doctor visits, preventive services, and diagnostic tests like MRIs. Most MRI scans performed outside of an inpatient hospital stay, such as in a doctor’s office or independent diagnostic testing facility, are covered under Part B. Part B covers medically necessary services for diagnosing or treating health conditions.

Medicare Advantage Plans (Part C) are offered by private companies approved by Medicare. These plans must provide at least the same benefits as Original Medicare (Parts A and B). Many also include additional benefits and may have different cost-sharing structures. Beneficiaries should review their plan details to understand MRI coverage and potential out-of-pocket costs.

Coverage Conditions for MRI Scans

Medicare covers MRI scans based on “medical necessity.” A healthcare provider must determine the MRI is required to diagnose, treat, monitor, or guide treatment for a medical condition. The scan cannot be solely for screening purposes.

An MRI scan must be ordered by a physician or other qualified healthcare professional who accepts Medicare assignment. This order documents medical necessity for billing. The facility where the MRI is performed must be Medicare-approved and accept Medicare patients. If obtained from a physician, clinic, or freestanding radiology center outside of a hospital, the provider must be accredited for Medicare to cover the test.

Medicare generally does not cover experimental or investigational procedures. While routine costs of qualifying clinical trials, including diagnostic tests, may be covered, the experimental treatment itself is typically not covered unless specific conditions are met, such as participation in a Coverage with Evidence Development (CED) study. Therefore, an MRI must be a recognized and established diagnostic tool for the condition in question.

Costs and Payments

Even when Medicare covers an MRI scan, beneficiaries typically have out-of-pocket costs. For outpatient MRI scans covered under Medicare Part B, beneficiaries must first meet their annual Part B deductible. After the deductible is satisfied, Medicare Part B generally pays 80% of the Medicare-approved amount for the MRI, leaving the beneficiary responsible for the remaining 20% coinsurance.

If the MRI is performed in a hospital outpatient department, in addition to the Part B coinsurance, a separate copayment may apply for the facility services. This hospital outpatient copayment can vary and, in most cases, cannot exceed the Part A hospital stay deductible. The total out-of-pocket cost can depend on factors such as the specific facility, whether it is in-network for Medicare Advantage plans, and the complexity of the scan.

Medicare Advantage plans (Part C) have varying cost-sharing structures, including different deductibles, copayments, and coinsurance amounts for services like MRIs. While these plans are required to cover at least what Original Medicare covers, the out-of-pocket expenses can differ significantly from plan to plan. Beneficiaries with Medicare Advantage plans should consult their plan’s specific benefits information to understand their financial responsibility.

Appealing a Coverage Decision

If Medicare denies coverage for an MRI scan, beneficiaries have the right to appeal the decision. The appeal process involves several levels, allowing for a review of the initial denial. The first step is typically a “redetermination” by the Medicare Administrative Contractor (MAC) that processed the claim.

Beneficiaries usually receive a Medicare Summary Notice (MSN) or an Explanation of Benefits (EOB) from their Medicare Advantage plan, which outlines the denial reason and appeal instructions. It is important to gather all relevant medical documentation, including the doctor’s order and any supporting clinical notes, to strengthen the appeal. The appeal process has specific timeframes for submission at each level, and adhering to these deadlines is important. If the initial appeal is unsuccessful, further levels of appeal, such as reconsideration by a Qualified Independent Contractor (QIC) or a hearing before an Administrative Law Judge (ALJ), may be pursued.