Does Medicare Pay for an Echocardiogram?

An echocardiogram is a non-invasive diagnostic test that uses sound waves to create moving images of the heart. This procedure, also known as an “echo,” assesses the heart’s function and structures, including its chambers, valves, and blood flow. Understanding Medicare coverage for this diagnostic test is important for beneficiaries. This article clarifies Medicare coverage for echocardiograms.

Medicare Coverage for Diagnostic Tests

Medicare Part B serves as the primary coverage for outpatient diagnostic tests such as echocardiograms. This part of Original Medicare helps cover services from doctors and other healthcare providers, along with outpatient care and some preventive services. If performed in an outpatient setting, Part B generally covers the test, provided certain conditions are met.

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies. These plans are required to cover at least the same services as Original Medicare Parts A and B, including medically necessary echocardiograms. However, Medicare Advantage plans may have different rules regarding network providers and referrals, which can influence where beneficiaries receive their care.

If an echocardiogram is conducted during an inpatient hospital stay, Medicare Part A covers the test. Part A generally covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. If a beneficiary is formally admitted to a hospital and an echocardiogram is part of their inpatient treatment, Part A applies.

Medical Necessity and Physician Orders

For Medicare to cover an echocardiogram, the test must be considered medically necessary. Medical necessity means a physician has ordered the test and it is appropriate for diagnosing or treating a specific medical condition. This requirement ensures Medicare funds are used for services directly related to a beneficiary’s health needs.

Several symptoms or conditions commonly lead to a medically necessary echocardiogram. These may include unexplained chest pain, shortness of breath, irregular heartbeats, or the presence of a heart murmur. Physicians may also order an echocardiogram to monitor an existing heart condition, assess heart damage after a heart attack, or evaluate heart function before certain surgeries. The test provides detailed images that help doctors understand the heart’s size, shape, and pumping ability.

A physician’s order or referral is required for Medicare coverage of an echocardiogram. Without a documented medical reason and a physician’s directive, the test is unlikely to be covered. Routine or screening echocardiograms are generally not covered unless specific symptoms, risk factors, or medical conditions justify it as medically necessary for diagnosis or treatment.

Patient Costs and Financial Responsibility

Even when an echocardiogram is covered by Medicare, beneficiaries incur some out-of-pocket costs. Under Medicare Part B, an annual deductible applies before Medicare pays. For 2025, the Medicare Part B deductible is $257. After this deductible is met, beneficiaries are generally responsible for a coinsurance amount, which is 20% of the Medicare-approved amount for the service.

The remaining 80% of the Medicare-approved amount is paid by Medicare. For example, if the Medicare-approved amount for an echocardiogram is $1,000, and the deductible has been met, Medicare pays $800, and the beneficiary owes $200. These costs can vary slightly based on the facility where the service is performed, such as an outpatient hospital department versus an independent diagnostic facility.

Supplemental insurance policies, such as Medigap plans, can help cover some or all of these out-of-pocket costs, including the Part B deductible and coinsurance. Medigap plans work alongside Original Medicare to reduce a beneficiary’s financial responsibility. Similarly, Medicare Advantage plans may offer different cost-sharing structures, such as copayments, which can impact the total out-of-pocket expense for an echocardiogram.

Verifying Coverage and Handling Claims

Before undergoing an echocardiogram, beneficiaries should confirm with their ordering physician and the diagnostic facility that the test is medically necessary. It is also important to verify that the facility accepts Medicare assignment, meaning they accept the Medicare-approved amount as full payment. This step helps prevent unexpected charges.

Providers may issue an Advanced Beneficiary Notice of Noncoverage (ABN) if they believe Medicare may not cover a service. An ABN is a written notice that informs the beneficiary that Medicare may deny payment for a service or item, and if signed, the patient agrees to be financially responsible if Medicare denies the claim. Understanding this document is important before receiving the service.

If a claim for an echocardiogram is denied, beneficiaries will receive a Medicare Summary Notice (MSN), which explains what services were billed, what Medicare paid, and the reason for any denial. The MSN also provides information on appeal rights, allowing beneficiaries to challenge Medicare’s decision if they believe the service should have been covered. Maintaining records of medical orders and communications with providers and Medicare can be helpful throughout this process.

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Disclaimer: This article provides general information about Medicare coverage for echocardiograms. Specific coverage details can vary based on individual circumstances, plan types, and current Medicare regulations. It is always advisable to consult with your healthcare provider, Medicare, or your specific Medicare plan for personalized information.