Does Your Insurance Cover a DEXA Scan?

A Dual-energy X-ray Absorptiometry (DEXA) scan measures bone mineral density, primarily to diagnose osteoporosis and assess fracture risk. It also monitors the effectiveness of osteoporosis treatments. A common consideration for individuals needing this scan is whether their health insurance will cover the associated costs. This article provides guidance on understanding typical coverage scenarios and how to confirm specific insurance benefits.

Medical Necessity and Coverage Criteria

Insurance coverage for a DEXA scan depends on it being medically necessary, aligning with established clinical guidelines and a healthcare provider’s recommendation. Insurers typically cover DEXA scans for women aged 65 and older and men aged 70 and older as part of routine screening for osteoporosis. Younger individuals may also qualify if they have specific risk factors. These risk factors commonly include a history of fragility fractures, certain medical conditions like hyperparathyroidism, or long-term use of specific medications such as corticosteroids.

Monitoring osteoporosis treatment or assessing individuals with signs of bone issues on X-rays also meets the medical necessity criteria. While most plans typically cover a DEXA scan once every two years, more frequent testing may be covered if a medical professional determines it is justified by the patient’s condition. A doctor’s order or referral is a requirement, as it provides the clinical justification that insurers need to consider coverage.

Navigating Your Insurance Policy

Understanding the specific details of your health insurance policy is important, even when a DEXA scan is medically necessary. Key financial terms like deductibles, copayments, coinsurance, and out-of-pocket maximums directly affect your financial responsibility. A deductible is the amount you pay for covered services before your insurance begins to pay, though preventive care may be exempt. After meeting your deductible, you may pay a copayment (a fixed amount for a service) or coinsurance (a percentage of the cost shared between you and your insurer).

These costs contribute to your out-of-pocket maximum, the most you will pay for covered services in a plan year before your insurer covers 100% of eligible costs. Many insurance plans require pre-authorization for diagnostic tests like a DEXA scan. Without this pre-authorization, even a medically necessary scan might not be covered, leading to payment denial. Information regarding policy specifics, including pre-authorization requirements, can be found on your insurance company’s website, member portal, or within your plan’s benefits summary or member handbook.

Confirming Coverage with Your Insurer

After understanding the general medical necessity and your policy’s terms, the next step is to verify coverage with your insurance company. You can find the member services phone number on your insurance card, or explore online chat and member portal messaging options. When contacting them, be prepared with your policy information and the specific reason for the DEXA scan. It is helpful to inquire whether a DEXA scan, often identified by CPT codes such as 77080 or 77081, is covered for your particular medical reason.

You should also ask if pre-authorization is required for the service and clarify who is responsible for submitting it, whether it is your doctor’s office or yourself. Inquire about your estimated out-of-pocket costs, including any deductible, copayment, or coinsurance that may apply. Additionally, confirm if there are specific in-network providers or facilities you must use to ensure coverage. It is a good practice to document the call by noting the date, time, the representative’s name, and any reference numbers provided.

What to Do If Coverage is Denied

If your insurance coverage for a DEXA scan is denied, understanding the specific reason for the denial is the first action to take. Reasons for denial can include a determination that the scan was not medically necessary, a lack of required pre-authorization, or using an out-of-network provider. You have the right to appeal the insurer’s decision, starting with an internal appeal directly to the company. This involves submitting a formal request for reconsideration, often with additional medical documentation from your doctor to support the medical necessity of the scan.

If the internal appeal is denied, you may have the option to request an external review, where an independent third party reviews your case. This external review process is binding on the insurance company. If insurance coverage is not an option, you can discuss self-pay options with the healthcare provider, as many offer discounted rates for upfront cash payments. Exploring payment plans or comparing prices at different imaging centers can also help manage the cost of the scan.