Does Medicare Cover a PET Scan?

Does Medicare Cover a PET Scan?

PET scans help your doctor diagnose disease early, while it’s easier to treat.

Did your doctor recently order a PET scan to find causes for the symptoms you are currently experiencing? You probably have many questions and concerns – not only about your health but also about the PET scan process – and Medicare coverage of PET scans.

First, take a deep breath. Just because you are going through diagnostic testing doesn’t mean something is dreadfully wrong. Also, if you have Medicare Part B coverage, you should have help paying for PET imaging.

Here is the essential information you need to know about PET scans. We will discuss what it is, how it works, what to expect from the test – and the Medicare coverage of a PET scan.

What is a PET scan?

Positron emission tomography scans (PET scans) produce images of your organs and tissues at work – including the heart and the brain.

Unlike MRIs (magnetic resonance imaging) and CT scans (computed tomography scans), which detect illness by revealing structural changes in organs and tissues, a PET scan sends a radioactive substance into the bloodstream to check for biochemical changes. This means a PET scan can find signs of disease earlier than other tests.

How a PET scan works

A PET scan works like this: a radioactive substance called a radiotracer is injected into the body, typically intravenously – but it can be taken orally or administered as a breathable gas.

As the radiotracer travels through your blood, a scanner moves over the body, picking up signals given off by the tracer to create computer-generated 3D images. These images show how much cell activity is occurring in the body – and where.

By analyzing blood flow, oxygen use, and metabolism, the test can pinpoint problem areas. For example, cancer cells or damaged tissue show up easily on the test.

Why would someone need a PET scan?

Please understand that while a PET scan is used in the initial diagnosis of disease, it can also rule out conditions, assess the effectiveness of treatment, or identify areas that would benefit from procedures or surgeries.

Here are some of the diseases or conditions that can be diagnosed with a PET scan:

  • Cancer, including breast cancer, lung cancer, neck cancer, cervical cancer, melanoma, and thyroid cancer
  • Coronary artery disease or other heart problems
  • Brain disorders, such as brain tumors, dementia, and epilepsy

It’s worth noting that in the summer of 2023, The U.S. Centers for Medicare and Medicaid Services reconsidered its national coverage determination (NCD) of amyloid PET scans for diagnosing and managing patients with Alzheimer’s disease. Currently, Medicare limits Alzheimer’s disease patients to a single PET scan if they are enrolled in a clinical trial.

We mention this so you understand that coverage is constantly changing. The use of PET scans is always changing, too.

Does Medicare cover PET scans?

Yes, Original Medicare covers diagnostic tests, including PET scans, CT scans, MRIs, EKGs, and X-rays when your doctor orders them to treat a medical problem.

Medicare Part B and PET scan coverage

Medicare Part B (medical insurance) typically covers diagnostic, non-laboratory tests performed in a doctor’s office or independent diagnostic testing facility.

After you meet the Part B deductible, those with Medicare will pay 20% of the Medicare-approved amount of the PET scan.

Medicare Part A and PET scan coverage

If you get the PET scan at a hospital as an outpatient, you also pay a copayment, which may be more than 20% of the Medicare-approved amount. However, in most cases, this amount can’t be more than the Part A hospital stay deductible.

How do Medicare Advantage & Medigap plans cover PET scans?

Medicare Advantage plans cover everything Original Medicare covers, so your PET scan will be covered as long as you meet other criteria, such as the test being deemed medically necessary by your provider.

A Medigap plan, sold by private health insurance companies, helps pay some of the costs Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles. If Medicare is covering your PET scan, your Medigap plan will, too.

Not all Medicare plans offer the same coverage – or even the same costs. Compare your options with our Find a Plan tool. Just enter your zip code to review the costs and benefits of Medicare plans in your area.

How to prepare for a PET scan

You must follow your healthcare provider’s instructions when you are scheduled to have a PET scan.

A patient is usually instructed not to eat anything at least six hours before the test. You may also be advised to drink only water and to avoid caffeine leading up to the PET scan.

What to expect from a PET scan

A PET scan is painless.

First, you’ll receive an injection of a radiotracer. You’ll sit in a chair for about an hour while the radiotracer moves throughout your bloodstream.

After an hour, you’ll lie on an exam table that slides in and out of the PET/CT scanner. The opening of the PET scan machine is about 30 inches in diameter. Some patients with claustrophobia may feel uncomfortable going through the narrow door. However, you must remain still during the test.

The scan can take about 30 minutes to complete. After the test, you’ll need to wait while the technologist reviews the scans to ensure the images are clear.

Additional resources

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