Does Medicare Part B Cover Prostate MRI?

Medicare Part B provides coverage for a prostate magnetic resonance imaging (MRI) scan when specific medical conditions are met and the procedure is deemed medically necessary. A prostate MRI uses strong magnetic fields and radio waves to create detailed images of the prostate gland and surrounding tissues. This advanced imaging technique helps medical professionals diagnose various prostate conditions, evaluate the extent of prostate cancer, and guide treatment decisions.

Medicare Part B Coverage Criteria

Medicare Part B covers outpatient services, including diagnostic imaging, when medically necessary. This means the service must be required to diagnose or treat an illness, injury, condition, or its symptoms, and meet accepted medical standards. For a prostate MRI to be covered, a physician or other healthcare provider must order the test. The imaging procedure must also be performed in a Medicare-approved facility.

Specific Medical Conditions for Coverage

A prostate MRI is considered medically necessary by Medicare under several clinical situations. It is commonly covered for the diagnosis or staging of prostate cancer, providing detailed images that help determine if cancer is present and whether it has spread. This imaging can also assist in guiding biopsies to suspicious areas, increasing the accuracy of tissue sampling.

Coverage extends to situations involving elevated Prostate-Specific Antigen (PSA) levels, particularly when previous biopsies have been negative but concern for cancer persists. Prostate MRIs are also covered for monitoring low-risk prostate cancer under active surveillance or if clinical concerns arise.

Additionally, a prostate MRI may be covered to assess suspected local recurrence after prostate cancer treatment. The scan can detect if cancer has returned or if it is growing outside the prostate gland. Other conditions, such as prostate infection (prostatitis), prostate abscess, or an enlarged prostate (benign prostatic hyperplasia), may also warrant coverage if the MRI is needed for diagnosis or evaluation.

Understanding Your Out-of-Pocket Costs

Even when a prostate MRI is covered by Medicare Part B, beneficiaries incur out-of-pocket costs. These include an annual deductible, which is $257 in 2025. After meeting this deductible, Medicare Part B covers 80% of the Medicare-approved amount for the service.

The remaining 20% is the patient’s coinsurance responsibility. It is important to confirm that the healthcare provider and imaging facility “accept assignment,” meaning they agree to accept the Medicare-approved amount as full payment for the service, preventing excess charges.

If a provider does not accept assignment, they may charge up to 15% more than the Medicare-approved amount, and you would be responsible for this additional cost, along with your 20% coinsurance. Supplemental insurance plans, like Medigap, or Medicare Advantage plans may cover some or all of these out-of-pocket expenses, depending on the specific plan’s benefits.

Steps to Confirm Eligibility and Coverage

Before undergoing a prostate MRI, proactive steps can help confirm eligibility and coverage. First, discuss with your ordering physician the medical necessity of the MRI for your specific condition. Ensure your medical records clearly document the qualifying diagnosis or clinical indication that supports the need for the scan.

Confirm that both the physician ordering the MRI and the imaging facility accept Medicare assignment. This ensures they will bill Medicare directly and adhere to the Medicare-approved payment rates, limiting your financial responsibility. You should also inquire about any prior authorization requirements.

While traditional Medicare rarely requires prior authorization for diagnostic tests like an MRI, some Medicare Advantage plans may have specific rules. If you have a Medicare Advantage plan, contact your plan directly to understand their network requirements and whether prior authorization is needed before your procedure.