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 will cover PET scans in most cases. This usually falls under Medicare Part B.
A PET scan — or a positron emission tomography scan — is an imaging tool that lets doctors see how well your tissues and organs are working. It’s often used in diagnosing and staging 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 the bulk of the test’s cost.
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 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, or 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.
The Centers for Medicare & Medicaid Services (CMS) has a specific list detailing the criteria.
What other types of routine imaging tests are covered?
When diagnostic testing is ordered by your doctor for a medical reason to diagnose or treat 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 besides PET scans that Medicare covers are:
- computed tomography (CT) scans
- electrocardiograms (ECGs/EKGs)
- magnetic resonance imaging (MRI) scans
You can check if a particular scan or test is covered by Medicare 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.
- For each benefit period — like hospitalization for a specific diagnosis — you’ll pay a deductible of $1,600 in 2023.
- 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 $164.90 for most people in 2023
- a $226 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 $226 deductible for 2025, 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.
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 that have increased metabolism — or more chemical activity. There’s 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
What to expect during a PET scan
When you’re getting ready for a PET scan, you may be asked to change into a hospital gown and empty your bladder before the test begins.
At the start of the scan, you’ll be given the tracer that you’ll inhale, swallow, or have injected. You will wait about an hour while your body absorbs the tracer.
You’ll then be asked to lie on a padded table. You’ll be placed within a large scanner with a circular shape. The machine, which looks like a CT scanner, will buzz and click as it completes your scan.
You shouldn’t feel any pain, and the technician running the test will tell you when to lie still and when the test is completed.
After the test, you may get dressed and go home. You will probably be advised to drink a lot of fluids to help flush the rest of the tracer from your body. Your doctor will contact you to go over the results of the PET scan.
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?
In order for you to get a PET scan covered by Medicare, it must be ordered by a doctor for medically necessary reasons. 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.
A PET scan is used to give your doctor a detailed look at how well the tissues and organs in your body 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.