A Dual-energy X-ray absorptiometry, commonly known as a DEXA scan, is a low-dose X-ray procedure that measures bone mineral density. This diagnostic tool plays a significant role in identifying and monitoring conditions like osteopenia and osteoporosis, helping diagnose bone loss and evaluate treatment effectiveness. Medicare covers DEXA scans when specific medical conditions and criteria are met.
Medicare Part B Coverage for DEXA Scans
Medicare Part B, which serves as medical insurance, typically covers DEXA scans as a preventive service for eligible beneficiaries. These scans are covered when deemed medically necessary by a physician to diagnose or monitor specific health conditions. For most individuals, Medicare Part B covers one bone mass measurement every 24 months. More frequent coverage may be approved if medical necessity dictates.
Eligibility Criteria for Covered Scans
Medicare Part B covers DEXA scans for individuals who meet specific medical criteria, requiring a doctor’s order that documents one of these qualifying conditions:
Women whose doctor determines they are estrogen-deficient and at a clinical risk for osteoporosis, based on their medical history.
Individuals presenting with vertebral abnormalities, identified through X-rays, that indicate osteoporosis, osteopenia, or vertebral fractures.
Patients receiving or expected to receive long-term glucocorticoid (steroid) therapy, equivalent to an average of 5.0 mg of prednisone or more daily for over three months.
A diagnosis of primary hyperparathyroidism, a condition affecting calcium regulation and bone health.
Individuals who are being monitored to assess their response to an approved osteoporosis drug therapy.
Understanding Your Out-of-Pocket Costs
Even with Medicare coverage, beneficiaries may have some financial responsibility for a DEXA scan. If the annual Medicare Part B deductible has not been met, individuals will be responsible for that amount first. After the deductible, Medicare Part B typically covers 80% of the Medicare-approved amount for the scan, leaving the patient responsible for the remaining 20% coinsurance. Medicare Advantage Plans (Part C) must provide at least the same benefits as Original Medicare, including DEXA scan coverage. However, these plans may have different cost-sharing structures, such as copayments, and might require using in-network providers. Supplemental insurance plans, like Medigap, can help cover the 20% coinsurance and potentially the deductible, reducing out-of-pocket expenses.
Securing Medicare Coverage for Your DEXA Scan
To ensure Medicare covers your DEXA scan, the process begins with your doctor. Your physician must order the scan and clearly document medical necessity based on eligibility criteria. Discussing your medical history and risk factors with your doctor helps ensure thorough documentation. Before the procedure, confirm the facility accepts Medicare assignment, meaning they agree to Medicare’s approved payment amount and help prevent unexpected charges. It is also advisable to discuss potential out-of-pocket costs with your healthcare provider or contact Medicare directly for clarification on your specific plan’s coverage and any remaining financial obligations.