Does Medicare Cover Pulmonary Function Tests?

Pulmonary function tests (PFTs) measure how well your lungs are working by assessing how much air you can hold, how quickly you can move air in and out, and how effectively your lungs transfer oxygen into your bloodstream. These non-invasive tests help healthcare providers diagnose and monitor various respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), and emphysema. PFTs can also evaluate the impact of environmental exposures on lung health or assess lung function before surgery.

Medicare Coverage for Pulmonary Function Tests

Original Medicare, specifically Part B, generally covers pulmonary function tests when medically necessary. Part B covers outpatient medical services, including doctor’s visits, diagnostic tests, and preventive services. If your healthcare provider determines a PFT is needed to diagnose or manage a respiratory condition, Part B typically provides coverage.

Medicare Advantage Plans (Part C) are offered by private insurance companies and must cover at least the same services as Original Medicare Part A and Part B, including medically necessary pulmonary function tests. While the coverage scope is similar, out-of-pocket costs and specific rules, such as provider networks, can vary between different Medicare Advantage plans.

Medicare Part A and Part D are typically not relevant for standalone outpatient pulmonary function tests. PFTs are generally performed in an outpatient setting, making Part B the primary source of coverage for these diagnostic services.

Conditions for Coverage

For Medicare to cover a pulmonary function test, specific conditions must be met, with medical necessity being a primary requirement. A healthcare provider must determine that the test is medically necessary for the diagnosis or treatment of a particular illness or injury. For instance, a PFT might be deemed necessary to evaluate persistent symptoms like shortness of breath or coughing, monitor the progression of a known lung disease, or assess lung function before a surgical procedure.

The test must also be ordered by a treating physician or other qualified healthcare professional who uses the results in the patient’s treatment. Medicare requires that all diagnostic tests, including PFTs, are ordered with a clear intent to be performed and that the medical record supports this necessity.

The pulmonary function test must be performed in an approved facility that accepts Medicare assignment. This typically includes a doctor’s office, clinic, or hospital outpatient department. The facility must adhere to Medicare’s standards for diagnostic testing.

Understanding Your Costs

Even with Medicare coverage, beneficiaries usually incur some out-of-pocket costs for pulmonary function tests. Under Original Medicare Part B, an annual deductible applies before Medicare begins to pay its share. For 2025, the Medicare Part B annual deductible is $257.

After the deductible has been met, beneficiaries are responsible for a 20% coinsurance of the Medicare-approved amount for most Part B services, including PFTs. There is no annual out-of-pocket maximum under Original Medicare, meaning coinsurance costs can accumulate.

A beneficiary might receive an Advance Beneficiary Notice of Noncoverage (ABN) from their provider before a PFT if Medicare is not expected to cover the service. This notice informs you that Medicare may deny payment and that you will be personally responsible for the cost if Medicare does not pay. Signing the ABN means you agree to pay for the service if Medicare denies the claim, while refusing to sign may mean the provider will not perform the service.

Medicare Advantage Plans (Part C) also have cost-sharing, but these costs can differ from Original Medicare. Instead of a 20% coinsurance, Medicare Advantage plans often use fixed copayments for services, which can vary by plan. These plans are required to have an annual maximum out-of-pocket limit for covered Part A and Part B services.