How Often Does Medicare Pay for a DEXA Scan?

A Dual-energy X-ray Absorptiometry (DEXA) scan is an imaging test that measures bone mineral density, primarily used to diagnose osteoporosis and assess fracture risk. This non-invasive procedure helps determine the strength and thickness of bones, often focusing on the lower spine, hip, and forearm. Medicare, as a federal health insurance program, provides coverage for medically necessary services, including DEXA scans, for its beneficiaries.

Medicare Part B Coverage Criteria

Medicare Part B covers medically necessary bone mass measurements, including DEXA scans. This coverage applies to individuals who meet specific medical indications. For example, individuals diagnosed with osteoporosis or those whose X-rays show signs of osteoporosis, osteopenia, or vertebral fractures typically qualify.

Coverage also extends to individuals receiving or expecting to receive long-term glucocorticoid (steroid) therapy, such as prednisone, for more than three months, due to its potential impact on bone health. Patients diagnosed with primary hyperparathyroidism, a condition affecting calcium stores, are also eligible. Finally, Medicare Part B covers DEXA scans for individuals being monitored to assess the effectiveness of an FDA-approved osteoporosis drug therapy.

Specific Coverage Frequency

For most eligible individuals, Medicare Part B covers a bone mass measurement once every 24 months. More frequent scans may be covered under specific medical circumstances when deemed necessary by a healthcare provider. For instance, if a patient is being monitored to assess their response to an FDA-approved osteoporosis drug therapy, scans might be covered more often. Additionally, significant changes in a patient’s medical condition or medication that necessitate closer monitoring of bone density can justify more frequent assessments. Such situations require the treating physician to document the medical necessity for the increased frequency.

Preparing for Your Scan

Before a DEXA scan, discussing the medical necessity and appropriate frequency with your primary care physician or specialist is important. Your doctor’s order, or referral, is a mandatory requirement for Medicare coverage of the scan. This order confirms the medical reason for the procedure.

It is also advisable to confirm that the imaging facility or provider accepts Medicare assignment. This step helps ensure maximum coverage and prevents unexpected out-of-pocket costs, as facilities accepting assignment agree to Medicare’s approved payment amount. Providing accurate and complete medical history to your doctor assists in justifying the scan under Medicare guidelines.

Understanding Costs and Next Steps

Medicare Part B generally covers 100% of the cost for a medically necessary bone mass measurement (DEXA scan) if it meets frequency guidelines and the provider accepts assignment. This means beneficiaries typically pay no Part B deductible or coinsurance for this specific preventive service. The provider usually submits the claim directly to Medicare for reimbursement.

After the scan, your doctor will discuss the findings and any necessary next steps, including potential treatment plans. If a claim is unexpectedly denied, you can contact Medicare or the provider to understand the reason and initiate an appeals process. The appeals process typically involves several levels, and you have the right to challenge the denial.