Is a DEXA Scan Covered by Insurance?

Dual-energy X-ray absorptiometry, commonly known as a DEXA scan, is a specialized imaging procedure that precisely measures bone mineral density. This non-invasive test primarily serves to detect conditions like osteoporosis, a disease that weakens bones and increases fracture risk. Understanding insurance coverage for a DEXA scan is a common concern.

Understanding DEXA Scans and Coverage Criteria

A DEXA scan measures bone mineral density, providing detailed insights into bone health. This measurement helps healthcare providers diagnose osteoporosis, assess an individual’s risk of future fractures, and monitor the effectiveness of treatments for bone conditions. The most common areas scanned are the hips and spine, which are susceptible to bone loss.

Insurance coverage for a DEXA scan is contingent upon “medical necessity,” meaning a healthcare provider determines the test is required for diagnosis or treatment. This necessity is established through clinical guidelines, which consider various risk factors. These factors include being a post-menopausal woman, a man over a certain age, or an individual with specific medical conditions like hyperparathyroidism or a history of long-term corticosteroid use. A doctor’s referral or prescription is a prerequisite, providing the necessary medical justification for insurance consideration. This referral should include relevant diagnosis codes, which explain the medical reason for the scan.

Key Factors Influencing Insurance Coverage

Medical necessity is the overarching requirement for DEXA scan coverage across all insurance types. Different insurance plans have specific rules and frequencies for reimbursement. For instance, Medicare Part B typically covers bone density tests once every 24 months for eligible individuals. Eligibility includes women determined to be estrogen-deficient and at risk for osteoporosis, individuals with vertebral abnormalities, those on long-term steroid therapy, or patients with primary hyperparathyroidism.

Medicaid coverage for DEXA scans varies by state, but generally adheres to medical necessity guidelines, often including specific age or risk factor criteria. Many state Medicaid programs will reimburse for medically necessary DEXA scans at a maximum of once every two years for women over 65 and men over 70. Private and employer-sponsored insurance plans also base coverage on medical necessity, outlining deductibles, co-pays, and co-insurance. The specific terms of a private policy, including whether a provider is in-network, significantly influence out-of-pocket costs. Most private plans typically cover routine bone density screening every two years, but may cover more frequent testing if medically justified.

Preparing to Confirm Your Coverage

Before scheduling a DEXA scan, gather specific information to confirm coverage. Obtain a written prescription from your healthcare provider, including specific diagnosis codes (ICD-10 codes) for the scan. Your provider should also include the correct procedure codes (CPT codes), such as 77080 for axial skeleton scans or 77081 for appendicular skeleton scans, which are crucial for accurate insurance verification.

Next, contact your insurance provider directly using the member services number found on your insurance card or by logging into their online portal. When speaking with a representative, ask specific questions about your policy’s coverage for a DEXA scan. Inquire if the scan is covered for your particular diagnosis code and whether pre-authorization or prior approval is required.

Understanding your potential out-of-pocket costs, including deductibles, co-pays, and co-insurance, is also important. Confirm if there are specific in-network facilities you must use to ensure coverage and avoid higher costs. Pre-authorization is where the insurer reviews medical necessity before the procedure; failure to obtain it when required can lead to denial.

Navigating Coverage and Potential Issues

After gathering information, secure any necessary pre-authorization. This process typically involves your healthcare provider submitting documentation, including medical history and diagnosis codes, to your insurer for review. Follow your insurance company’s specific instructions for this submission, which may involve online portals or faxing documents.

Following your scan, you will receive an Explanation of Benefits (EOB) from your insurer. This document details how your claim was processed, what the insurer paid, and any amount you may owe; it is not a bill. Carefully review your EOB to understand the coverage decisions made.

If a pre-authorization or claim is denied, common reasons include lack of medical necessity, missing pre-authorization, or using an out-of-network provider. You have the right to appeal a denial, which typically involves reviewing the denial letter to understand the specific reason. Subsequently, gather additional supporting medical documentation from your doctor and submit a formal appeal to your insurer, detailing why the service was medically necessary. If the internal appeal is unsuccessful, you may have the option to pursue an external review by an independent third party.

In situations where coverage is limited or denied, discussing payment plans with the imaging facility or inquiring about self-pay discounts, which can range from $100 to $250, may help manage costs.