Medicare covers a DEXA scan for bone density, but this coverage is specific to individuals who meet certain medical criteria under Medicare Part B. The dual-energy X-ray absorptiometry scan measures bone health, particularly for those at risk of bone loss conditions like osteoporosis. Understanding the conditions for coverage, frequency limits, and associated costs is important for beneficiaries planning their healthcare.
What is a DEXA Scan?
A DEXA scan (Dual-energy X-ray Absorptiometry) is a specialized, low-dose X-ray procedure used to measure bone mineral density (BMD). This test is the preferred method for assessing bone strength, typically focusing on the hip and spine, which are common sites for fractures. The measurements help providers diagnose osteoporosis, estimate future fracture risk, and monitor the effectiveness of treatments.
The procedure is non-invasive, quick, and painless, requiring the patient to lie still while the scanner passes over the body. The scan provides a T-score, comparing the patient’s bone density to a healthy young adult, and a Z-score, comparing it to people in the same age group.
Eligibility Requirements for Coverage Under Medicare Part B
Medicare Part B covers a “bone mass measurement,” which includes a DEXA scan, for qualified individuals once every 24 months as a preventive service. This coverage is triggered only when a person meets one of five specific medical criteria, as determined by a physician or qualified practitioner. While the standard frequency is once every two years, Medicare may cover the test more often if the physician determines that a more frequent measurement is medically necessary.
The five qualifying criteria for coverage are:
- A woman whose treating physician determines she is estrogen-deficient and at a clinical risk for osteoporosis based on her medical history.
- Individuals who have X-rays showing vertebral abnormalities, which can indicate osteoporosis, osteopenia, or a vertebral fracture.
- Those receiving or expecting to receive long-term glucocorticoid (steroid) therapy, defined as an average of 5.0 milligrams of prednisone or greater per day for more than three months.
- A person diagnosed with primary hyperparathyroidism, a condition that affects calcium stores and can lead to bone thinning.
- Individuals being monitored to assess the response to or effectiveness of an FDA-approved drug therapy for osteoporosis.
Patient Costs and Financial Responsibility
When a beneficiary meets the eligibility requirements, the DEXA scan is generally covered by Medicare Part B as a preventive service. The exact out-of-pocket cost depends on whether the provider accepts assignment. If the healthcare provider accepts Medicare assignment, the beneficiary pays nothing for the procedure, as the Part B deductible and coinsurance are waived for this specific service.
If the DEXA scan is performed for a diagnostic reason that falls outside the five specific preventive criteria, or if the provider does not accept assignment, the costs change. In a diagnostic scenario, the Part B deductible must be met first, after which the beneficiary is typically responsible for 20% of the Medicare-approved amount. Confirming that the facility and ordering provider accept assignment ensures the lowest possible out-of-pocket cost.
Coverage Through Medicare Advantage Plans
Beneficiaries enrolled in a Medicare Advantage Plan, also known as Medicare Part C, are also covered for DEXA scans. These private plans are required by law to offer, at minimum, the same benefits as Original Medicare (Parts A and B), including coverage for bone mass measurements when the medical eligibility criteria are met.
However, the patient’s financial responsibility and access to services may differ significantly under a Part C plan. Medicare Advantage plans often have different cost-sharing structures, which may involve copayments or coinsurance for the scan. These plans also typically operate with network restrictions. Therefore, a beneficiary must ensure the imaging facility is within their plan’s network to avoid higher costs or denial of coverage.