Does Medicare Pay for MRIs? Your Coverage Explained

Magnetic Resonance Imaging, commonly known as an MRI, is a diagnostic tool that uses strong magnetic fields and radio waves to create detailed images of organs, soft tissues, bone, and internal body structures. This non-invasive procedure helps healthcare providers diagnose a range of conditions, from torn ligaments to strokes, by providing clear visual insights into the body. Understanding how Medicare covers these services is important for beneficiaries navigating healthcare expenses.

Original Medicare Coverage for MRIs

Original Medicare, Parts A and B, provides coverage for medically necessary MRI scans. Coverage depends on whether the MRI is performed in an outpatient setting or as part of an inpatient hospital stay.

Medicare Part B covers outpatient diagnostic tests, including MRIs, when a doctor orders them. It must be medically necessary to diagnose or treat a condition, and performed by a Medicare-approved provider and facility. After meeting the annual Part B deductible ($257 in 2025), beneficiaries are responsible for 20% of the Medicare-approved amount for the MRI.

Medicare Part A covers medically necessary MRIs as part of a covered inpatient hospital or skilled nursing facility stay. The MRI cost is bundled into the overall inpatient service. A deductible applies for each benefit period ($1,676 in 2025).

Medicare Advantage Plan Coverage for MRIs

Medicare Advantage (Part C) plans, offered by private insurance companies, cover MRI scans. These plans are required by law to provide at least the same level of coverage as Original Medicare (Parts A and B). However, specific costs, rules, and network restrictions for MRIs can differ significantly among plans.

Medicare Advantage plans have different cost-sharing structures, such as copayments or coinsurance, for diagnostic services like MRIs. These plans also include an annual out-of-pocket maximum, which limits how much beneficiaries pay for covered services in a year. This maximum can vary by plan, providing a cap on yearly expenses that is not present in Original Medicare.

Some Medicare Advantage plans utilize provider networks; beneficiaries may incur higher costs or receive no coverage if they obtain an MRI outside the plan’s network. Additionally, some plans may require referrals from a primary care doctor or prior authorization before an MRI. These requirements are common features that distinguish Medicare Advantage plans from Original Medicare.

Key Considerations for MRI Coverage

For an MRI to be covered by Medicare, whether Original Medicare or a Medicare Advantage plan, it must be medically necessary. Medical necessity means the service is reasonable and appropriate for diagnosing or treating an illness or injury, and it aligns with accepted standards of medical practice.

A licensed doctor or other healthcare provider must order the MRI for it to be covered. This order confirms the test is needed for diagnosis or treatment. For Original Medicare, a healthcare professional must consult a clinical decision support mechanism (CDSM) before ordering certain advanced imaging services, including MRIs.

Prior authorization is a process where your plan must approve a service before you receive it. This is common with Medicare Advantage plans, which may deny coverage if prior authorization is not obtained. The process involves the healthcare provider submitting documentation to the plan to demonstrate the medical necessity of the MRI.

Understanding potential out-of-pocket costs is important. Deductibles are amounts paid before coverage begins. Coinsurance is a percentage of the cost paid after meeting your deductible, while a copayment is a fixed amount. Medicare Advantage plans provide an out-of-pocket maximum, the most you will pay for covered services in a plan year.

Regarding billing, Medicare-approved providers who accept Medicare assignment cannot balance bill, meaning they cannot charge more than the Medicare-approved amount. If a provider does not accept Medicare assignment but has not opted out of Medicare, they may charge a “limiting charge” up to 15% above the Medicare-approved amount. Facility fees can be charged by hospital-owned outpatient clinics, covered by Original Medicare with a 20% coinsurance, but Medicare Advantage plan coverage for these fees varies.