Medicare may cover positron emission tomography (PET) scans. However, a doctor must generally order the scan, and it must be for a medically necessary reason.

A person may have a PET scan for various reasons, including to detect cancer and heart issues. Medicare may cover the cost of these scans, depending on the circumstances and the type of plan a person has.

This article explains Medicare coverage for PET scans. It also goes over the costs associated with Medicare. Finally, it discusses PET scans and their uses.

Glossary of Medicare terms

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:

  • Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
  • Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
  • Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
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Medicare is a federal health insurance program. It has various parts, including:

  • Part A is hospital insurance, including hospice care. This is one part of Original Medicare.
  • Part B is medical insurance, including medical supplies and doctor’s appointments. This is the second part of Original Medicare.
  • Part C, also known as Medicare Advantage, provides the same coverage as Original Medicare (parts A and B). It may also offer additional benefits.
  • Part D covers prescription drugs.

A person may get coverage from various Medicare parts, depending on certain conditions.

Part A

If a person gets a PET scan while temporarily staying in a nursing facility or during a hospital stay, Medicare Part A may provide coverage.

Part B

Medicare Part B covers medically necessary services, including outpatient treatments. This means it may cover PET scans as diagnostic, non-laboratory tests.

For a person to qualify for coverage, a healthcare professional must order the test. The doctor must also consider the test medically necessary.

Medicare may also cover certain preventive and screening services. Individuals can find more information and check whether certain tests are covered by looking online or calling Medicare at 800-633-4227 (TTY: 877-486-2048).

Part C (Medicare Advantage)

Medicare-approved private insurance companies offer Medicare Part C plans, also known as Medicare Advantage plans. These plans must offer the same basic coverage as Original Medicare (parts A and B). They may also offer benefits such as dental coverage.

A person can check with their plan provider to find out whether they have coverage for a PET scan, either to diagnose a condition or check on an existing one.

Medigap

Medigap is supplemental insurance designed to provide coverage for additional costs that Original Medicare does not cover, including deductibles, copayments, and coinsurance.

There are different costs associated with the various Medicare parts.

Part A

Generally, a person does not pay a premium for Medicare Part A. It is often regarded as a premium-free plan because payroll taxes cover the costs.

However, there are exceptions. A $278 premium will apply for 2024 if a person paid Medicare tax for 30 to 39 quarters. A person who paid tax for fewer than 30 quarters will pay a premium of $505.

People who qualify for premium-free Medicare include those who are age 65 years and older and:

  • already receive retirement benefits from the Railroad Retirement Board (RRB) or the Social Security Administration (SSA)
  • are eligible for RRB or SSA benefits but have yet to enroll
  • have or had a spouse with Medicare-covered government employment

Part B

A person enrolled in Part A of Original can also get Part B benefits.

The Part B premiums are automatically deducted if a person gets benefit payments from the RRB, SSA, or Office of Personnel Management.

In 2024, the Part B premium is $174.70 per month for a person with an income of $103,000 or less, with an annual deductible of $240. After meeting the deductible, a person will generally pay 20% of Medicare-approved costs.

Part C (Medicare Advantage)

The cost for Part C (Medicare Advantage) plans depends on various factors, including the insurance provider and the specific plan that a person chooses. The amounts change each year.

Some plans have zero premiums, but a person still has to pay the Medicare Part B basic premium.

Medigap

A person enrolled in Original Medicare (parts A and B) can also have a Medigap plan. The plans generally cover out-of-pocket Medicare costs, including:

  • deductibles
  • coinsurance
  • copays

Medigap does not typically cover vision services, dental services, or prescription drugs.

Medigap costs vary by insurance company. Each company sets the premiums for its own Medigap policies. These premiums typically change every year.

A PET scan is a type of imaging test that helps diagnose medical conditions. It shows bodily activity on a cellular level by using radiation.

PET scans fall into two types. Healthcare professionals generally use myocardial Perfusion PET (also called Adenosine or Rubidium PET) for cardiac examinations. They can also use FDG PET to study the heart and brain to detect tumors or other types of infection.

Both PET scans use a radioactive tracer to visualize specific areas of the body.

Before the scan, a person is required to ingest, inhale, or receive an injection of a dye that has radioactive tracers, also called radiopharmaceuticals or radiotracers. A person’s organs absorb the tracers, which allows a medical professional to examine them.

PET scans are generally used in neurology, cardiology, and cancer treatment. They may be combined with an MRI scan or CT scan. A PET scan can help diagnose certain health conditions, check on an existing condition, and plan and confirm treatment.

A healthcare professional generally requests a PET scan.

What is it used to detect?

Healthcare professionals use PET scans to detect the following:

A PET scan can detect issues with oxygen intake, metabolism, and blood flow. It may show whether a cancer has spread or reoccurred. Healthcare professionals may also use PET scans to verify whether cancer treatment is effective.

Can everyone have a PET scan?

While a PET scan involves ingesting or coming into contact with radioactive tracers, exposure to radiation is minimal. However, some people may have an allergic reaction to the tracers.

If a person has allergies to certain substances, including aspartame, saccharin, and iodine, they should tell their healthcare professional before the test.

In addition, a person who is pregnant or nursing or has claustrophobia may want to speak with their healthcare professional before taking the test.

Original Medicare (parts A and B) and Part C (Medicare Advantage) plans may offer coverage for PET scans. A healthcare professional must order the PET scan, and it must be for a medically necessary reason.

Whether Medicare covers PET scans can also depend on the circumstances. For example, if a person is receiving inpatient care in the hospital, PET scans may be part of their Medicare coverage during that time.

Individuals can check online for more information about what tests Medicare covers. They can also speak with a representative by calling Medicare at 800-633-4227 (TTY: 877-486-2048).