A Dual-Energy X-ray Absorptiometry, or DEXA scan, is a non-invasive imaging test that measures bone mineral density (BMD), typically in the hip and spine. This procedure is the gold standard for diagnosing osteoporosis and assessing fracture risk. Coverage is not automatic and depends heavily on whether the scan is deemed medically necessary by the payer. The distinction between a health screening and a diagnostic test is a primary factor in determining insurance coverage.
Defining Medical Necessity for DEXA Coverage
Insurance coverage for a DEXA scan is tied to “medical necessity,” meaning the test must be required to diagnose or manage a specific disease or condition. Insurers, including Medicare and private companies, have established criteria based on a patient’s risk factors for bone loss and fracture. This approach ensures that the test is used on patients who will benefit most from early intervention.
Post-menopausal women are a frequent focus for testing, especially those who are not taking estrogen or who have other risk factors for osteoporosis. Men aged 70 and older are also commonly covered for routine screening, while younger individuals must demonstrate specific risk factors. Patients with a history of vertebral abnormalities or those who have had a fragility fracture are generally considered eligible for coverage.
The long-term use of certain medications, such as glucocorticoid (steroid) therapy equivalent to a minimum of 5.0 milligrams of prednisone daily for more than three months, also qualifies a patient. Individuals diagnosed with primary hyperparathyroidism, which can affect calcium levels and bone strength, are also generally approved. Once a patient is diagnosed with osteoporosis, follow-up scans are typically covered to monitor the effectiveness of drug therapy.
A DEXA scan performed purely for body composition analysis—measuring fat and muscle mass—is considered a wellness service and is not covered by medical insurance. Coverage is limited to bone density testing for osteoporosis and related conditions, not for general fitness tracking. Even preventative screening must meet the payer’s high-risk criteria to be covered.
Understanding Different Payer Coverage Structures
Coverage for DEXA scans differs significantly across the major types of insurance payers, even if the underlying medical necessity criteria are similar. Medicare, which covers many of the highest-risk older adults, provides standardized guidelines for bone mass measurements. Medicare Part B generally covers a DEXA scan once every 24 months for qualifying beneficiaries.
Medicare eligibility includes women 65 and older, men 70 and older, and younger individuals with specific medical conditions like hyperparathyroidism or those on long-term steroid therapy. If a physician determines that more frequent monitoring is necessary, Medicare may approve a scan more often than every two years. If a facility accepts Medicare assignment, eligible patients typically have no out-of-pocket costs for the covered bone density scan.
Medicaid coverage for DEXA scans varies by state, but policies generally align with the established standards for high-risk individuals. Coverage for private insurance plans, such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs), is more variable. These commercial plans often adopt the same risk criteria used by Medicare and consensus organizations like the National Osteoporosis Foundation.
Private insurers frequently require prior authorization before approving a DEXA scan, even when medical necessity criteria are met. The patient’s specific plan details, including the deductible status and network restrictions, will ultimately determine the coverage. Patients should always confirm their plan’s requirements, as a referral from a healthcare provider is often a prerequisite for coverage.
Navigating the Financial Landscape and Out-of-Pocket Costs
Even when a DEXA scan is covered by insurance, patients are often responsible for a portion of the cost through various forms of cost-sharing. This begins with the prior authorization process, a formal request from the provider confirming medical necessity. Receiving prior authorization ensures the claim will be paid, although it is not a guarantee of payment.
If the scan is approved, the patient’s financial responsibility is determined by their plan’s structure, including deductibles, co-insurance, and co-pays. A patient may need to satisfy an annual deductible before the insurance plan begins to pay, or they may be responsible for a co-insurance percentage, such as 20% of the allowed cost. Co-pays are fixed amounts paid at the time of service, potentially covering the specialist visit or the facility fee.
Frequency limitations are another key financial consideration, particularly the common restriction of one covered scan every 24 months. If a patient requests a follow-up scan too soon and it is not explicitly deemed medically necessary for monitoring treatment, the insurer will likely deny the claim. In this scenario, the patient will be responsible for 100% of the cost, moving the procedure into the self-pay category.
For patients who do not meet the medical necessity criteria or lack insurance, the self-pay cost for a bone density DEXA scan typically ranges between $100 and $300. The price varies based on the facility type, with medical offices and hospitals often charging more than private wellness centers. Patients can sometimes use funds from a Health Savings Account (HSA) or Flexible Spending Account (FSA) to cover these out-of-pocket costs.