PET scans are imaging studies that help doctors assess how your organs are functioning. They’re often done to diagnose and stage various cancers. Medicare Part B will cover PET scans in most cases.
A PET scan — or positron emission tomography scan — is an imaging tool that lets doctors see how well your tissues and organs are working. It’s often used to diagnose and stage various cancers.
Medicare will cover most of the cost of PET scans in many situations.
You can’t get a PET scan for just any type of problem. But if your doctor says you need one, Medicare should cover most of the test’s cost.
Here’s more information about what a PET scan is and what to expect if you need one.
Medicare Part B covers testing, appointments, and procedures when you aren’t staying in the hospital. These are called outpatient services.
Sometimes, your doctor may need to use certain imaging tools to make a diagnosis or tell how advanced a condition is. You might receive a PET scan in the hospital, but most of the time, this test will be performed as an outpatient service when ordered by your doctor.
You might receive a PET scan in one of the following places:
- hospital outpatient wing
- freestanding imaging center
- medical office
Medicare offers an online tool to help you find doctors and facilities that participate in Medicare in your area.
Where you have your scan determines how the test is paid for. For example:
- If you have a PET scan in the hospital, Medicare Part A will cover it.
- If you have a PET scan in an outpatient center, like those outlined above, Medicare Part B will cover it.
- If you have Medicare Advantage (Medicare Part C), your tests should also be covered. Medicare Advantage plans must cover at least the same basic services as Original Medicare (parts A and B). What you pay for your test, however, might differ depending on your plan.
Medicare Part B will cover your outpatient PET scan if your doctor orders the test and it’s considered medically necessary.
What other types of routine imaging tests are covered?
When your doctor orders diagnostic testing for a medical reason, such as diagnosing or treating a condition, it will be covered by your Medicare plan. Part A will cover these costs while you’re in the hospital, whereas Part B will cover these costs when you get the tests done in a medical building or testing center.
Some other imaging tests that Medicare covers include:
- computed tomography (CT) scans
- electrocardiograms (ECGs/EKGs)
- magnetic resonance imaging (MRI) scans
- X-rays
You can see if Medicare covers a specific scan or test by using this online search tool.
The amount a PET scan will cost you depends on where you have it done.
Part A costs
If you have a PET scan while you’re admitted as an inpatient in the hospital, Medicare Part A will cover your test. This means that:
- Your cost will be covered under your Medicare Part A coverage.
- In 2024, you’ll pay a deductible of $1,632 for each benefit period, such as hospitalization for a specific diagnosis.
- The cost of your test will count toward your Part A deductible.
- You won’t pay any coinsurance costs beyond that deductible amount unless you remain in the hospital for more than 60 days.
Part B costs
If you have a PET scan as an outpatient, Medicare Part B will cover your test. This means you’ll pay the following costs:
- your monthly Medicare Part B premium, which is $174.70 for most people in 2024
- a $240 deductible for the year
- coinsurance, which is 20% of the Medicare-approved amount for the PET scan after you’ve met your deductible for the year
This means that after you pay your $240 deductible for 2024, you’ll pay 20% of the cost of your PET scan. For example, if your PET scan costs $5,000 before coverage, you’d pay $1,000, and Medicare Part B will pay the remaining 80%, or $4,000 in this example.
Costs with private insurance plans
- If you have a Medicare Advantage plan, your share of costs may vary based on the plan you choose.
- When you have Original Medicare, you also have the option of using Medicare supplement insurance, known as Medigap, to help cover your coinsurance cost.
A PET scan is one of the tests a doctor might use to get a detailed view of what’s going on inside your body. The test uses a radioactive medication called a tracer. You might swallow or inhale it, or it might be injected into your veins for your test.
The tracer will show up brighter during the scan in areas with increased metabolism or chemical activity. There is usually more activity in areas of disease, like cancer.
Some of the reasons your doctor might order a PET scan include:
- characterization of pulmonary nodules
- diagnosis and staging of small cell lung cancer
- diagnosis and staging of esophageal cancer
- locating, diagnosing, and staging colorectal cancer
- diagnosing and staging some lymphomas
- diagnosing and staging some melanomas
- examining breast cancers after the initial diagnosis
- diagnosis and staging of head and neck cancers
- staging thyroid cancers
- presurgical testing for refractory seizures
- testing perfusion (blood flow) and viability of the heart in certain conditions
How many PET scans does Medicare cover per year?
Medicare will cover as many PET scans as you need as long as you meet the criteria. Different conditions that might require a PET scan have different criteria.
Does Medicare cover a full-body PET scan?
Medicare doesn’t place any limits on the scope of the PET scan as long as you’re getting it for a medically necessary reason.
Why would insurance deny a PET scan?
For you to get a PET scan covered by Medicare, your doctor must order it for a medically necessary reason. In terms of private insurance companies, some reasons for denial include:
- the approval required prior authorization
- there’s been an error
- there are some additional steps that were needed before the approval
- the insurance company has deemed the scan experimental or investigational
If you have a private insurance plan, it’s always a good idea to look through the details of your coverage and make sure you’re taking all the right steps. That said, there is usually a process for appealing a denied claim.
Read this guide about navigating your health insurance and learn more about insurance claim denials.
A PET scan is used to give your doctor a detailed look at how well your body’s tissues and organs are working.
These scans are often used to assess cancer or certain heart or brain conditions. Medicare will cover most of the cost of your PET scan, but you’ll still pay coinsurance costs.