Does Medicare Cover Ultrasounds? Costs and Rules

Medicare, the federal health insurance program for individuals aged 65 or older and certain younger people with disabilities, covers various medical services, including diagnostic tests like ultrasounds. Understanding this coverage helps beneficiaries receive necessary care without unexpected financial burdens.

General Criteria for Coverage

Medicare generally covers ultrasound tests when determined to be medically necessary. A qualified healthcare provider must order the ultrasound as a diagnostic tool to diagnose a specific health condition, rule out a possible illness, or monitor a previously diagnosed condition.

The Centers for Medicare & Medicaid Services (CMS) specifies that covered ultrasounds should be clinically effective and often serve as part of an initial patient evaluation. Ultrasounds are non-invasive procedures that use sound waves to create images of internal body structures, aiding in diagnosis and treatment guidance. They can evaluate blood flow, examine lumps, assess organ health, or guide procedures like biopsies. Medicare typically does not cover ultrasounds solely for general screening purposes unless specific criteria are met, such as a one-time screening for an abdominal aortic aneurysm for at-risk individuals.

Medicare Parts and Ultrasound Coverage

The specific Medicare part that covers an ultrasound depends on where the procedure takes place. This distinction helps beneficiaries understand their potential financial responsibilities.

Medicare Part A (Hospital Insurance)

Medicare Part A covers ultrasounds performed during an inpatient hospital stay. This includes services received in hospitals, medical centers, or skilled nursing facilities. If an ultrasound is part of inpatient care, its costs fall under Part A benefits.

Medicare Part B (Medical Insurance)

Medicare Part B is the most common coverage source for ultrasounds, covering outpatient services. This includes ultrasounds performed in a doctor’s office, an outpatient clinic, or a hospital outpatient department. Part B covers diagnostic imaging tests when ordered by a healthcare provider for medically necessary reasons. Certain preventive ultrasounds, such as a one-time abdominal aortic aneurysm screening for at-risk individuals, are also covered.

Medicare Part C (Medicare Advantage Plans)

Medicare Part C, known as Medicare Advantage, offers an alternative way to receive Medicare benefits through private insurance companies. These plans must cover at least everything Original Medicare (Parts A and B) covers, including medically necessary ultrasounds. Medicare Advantage plans can have different rules regarding networks, referrals, and cost-sharing structures. Some plans may also offer additional benefits beyond Original Medicare.

Your Out-of-Pocket Costs

Understanding potential out-of-pocket costs for an ultrasound under Medicare is important for financial planning. These costs vary based on the type of Medicare coverage and the service setting.

For ultrasounds covered under Medicare Part A during an inpatient stay, beneficiaries are responsible for the Part A deductible. In 2025, this deductible is $1,676 per benefit period. If the inpatient stay extends beyond 60 days in a benefit period, daily coinsurance amounts apply; for instance, $419 per day for days 61-90 in 2025.

For outpatient ultrasounds covered by Medicare Part B, beneficiaries must first meet the annual Part B deductible, which is $257 in 2025. After the deductible is met, Medicare typically pays 80% of the Medicare-approved amount, with the beneficiary responsible for the remaining 20% coinsurance. The standard monthly premium for Medicare Part B in 2025 is $185.00, though this can be higher for individuals with higher incomes.

Medicare Advantage (Part C) plans have their own cost-sharing structures, including varying copayments, coinsurance, and deductibles for diagnostic services. These plans often have an annual out-of-pocket maximum, providing financial protection once reached. Medigap policies, or Medicare Supplement Insurance, can also help cover some out-of-pocket costs associated with Original Medicare, such as deductibles, copayments, and coinsurance.

Ensuring Your Ultrasound is Covered

Taking proactive steps can help ensure Medicare covers your ultrasound. The process begins with your healthcare provider.

First, confirm your doctor provides a clear order for the ultrasound, explicitly stating its medical necessity for diagnosis or monitoring. Medicare generally covers ultrasounds when ordered by a physician and performed in a Medicare-accepting facility. Medicare does not typically cover ultrasounds used solely for screening purposes, with limited exceptions.

Next, verify that the facility or provider performing the ultrasound accepts Medicare assignment. Providers who accept assignment agree to accept the Medicare-approved amount as full payment for covered services, ensuring your out-of-pocket costs are limited to Medicare’s deductible and coinsurance amounts.

If you have a Medicare Advantage plan, check with your specific plan for any prior authorization requirements for diagnostic imaging services. While Original Medicare generally does not require prior authorization for ultrasounds, some private Medicare Advantage plans may have such stipulations. Always review your Explanation of Benefits (EOB) statement or contact Medicare or your plan directly if you have questions about specific costs or coverage details.