Does Insurance or Medicare Cover an MRI? What Is and Isn't Covered
How deductibles, coinsurance, prior authorization and Medicare Part B decide what you pay for an MRI, and when a scan is not covered at all.
Most health plans, Original Medicare and Medicaid cover an MRI when it is medically necessary and ordered by a clinician, but "covered" does not mean "free." Your share depends on your deductible, coinsurance or copay, whether the facility is in network, and whether your plan required prior authorization that was actually obtained. Scans done only for screening in people without symptoms, or ordered by no one, are often not covered. Read this guide before you book so you know which of those rules applies to you.
The four cost-sharing pieces on a commercial plan
Your plan's summary of benefits and coverage lists these. They combine to produce your bill.
| Term | What it means | How it affects an MRI |
|---|---|---|
| Deductible | The amount you pay first each plan year before the plan pays its share | Early in the year you may pay the full allowed amount |
| Coinsurance | A percentage you pay after the deductible (for example 20%) | You pay that percentage of the allowed amount |
| Copay | A flat fee for a service | Some plans charge a set amount for advanced imaging |
| Out-of-pocket maximum | The most you pay for covered in-network care in a plan year | Once reached, covered care is paid in full |
The allowed amount is the negotiated rate between your insurer and the provider, not the sticker price. Use the insured MRI out-of-pocket calculator to see how coinsurance and copays turn an allowed amount into your share.
Medical necessity and prior authorization
Insurers cover MRI when it is "medically necessary," meaning it is expected to help diagnose or treat a condition and matches the plan's clinical criteria. For many scans, particularly of the spine and joints, the plan requires prior authorization (also called precertification) before the scan.
- The ordering doctor's office usually submits the request, but you are the one billed if it is not done.
- Some plans require you to try conservative treatment, such as physical therapy, before approving a back MRI.
- An approval is for a specific scan code, facility and date range. Changing facilities can void it.
- If authorization is denied, you have the right to appeal. Ask for the denial in writing with the reason and the deadline.
Call the number on your insurance card, give the CPT code from the doctor's order and the facility name, and ask: Is this code covered? Is prior authorization required and on file? Is this facility and its radiologist in network? What is my expected share?
Original Medicare and MRI
Original Medicare Part B covers medically necessary diagnostic tests, including MRI, when your doctor orders them and the provider accepts Medicare. After you meet the annual Part B deductible, you generally pay 20 percent of the Medicare-approved amount. Medicare sets approved amounts, so a participating provider cannot charge you the high list price, although separate rules apply to hospital outpatient departments and independent facilities.
Key points:
- Screening MRI for people without symptoms is generally not covered.
- Medicare Advantage (Part C) plans must cover what Original Medicare covers but may use prior authorization, networks and different cost sharing. Check your plan.
- Medigap supplement plans can pay some or all of the 20 percent, depending on the plan letter.
- Inpatient MRIs fall under Part A and the hospital stay, with different cost sharing.
The Part B deductible and premium change every year. Confirm the current amounts at Medicare.gov or in your annual Medicare & You handbook instead of relying on a number you saw last year.
Medicaid and CHIP
Medicaid covers medically necessary imaging, but rules, authorization requirements and the list of participating providers differ by state. Many freestanding centers do not accept Medicaid, and some hospitals do. If you have Medicaid, call your managed care plan or state Medicaid office before scheduling, because a scan at a non-participating provider may not be covered at all.
When a scan may not be covered
- No order or no medical necessity: a scan you request without symptoms or a clinician's order.
- Elective whole-body or screening scans marketed directly to consumers.
- Out-of-network provider on a plan that does not cover out-of-network care.
- Missing prior authorization where the plan requires it.
- Repeat scans performed sooner than clinical criteria allow.
- Experimental or investigational uses according to your plan.
Should you pay cash even if you have insurance?
Sometimes. A person with a high deductible plan who has not met it may find that a freestanding center's cash price is lower than the plan's allowed amount at an in-network hospital. Before choosing cash, check three things:
- Does the cash payment count toward your deductible? Usually it does not unless you submit the claim and the insurer accepts it. Some states require plans to count certain out-of-network payments; ask your insurer.
- Is the lower price at a lower-cost facility that is also in network? Often the best answer is an in-network freestanding center, where you pay the plan's lower allowed amount.
- Will you reach your deductible anyway this year? If you expect more care, paying through insurance may help you hit your out-of-pocket maximum sooner.
Worked example (illustrative)
Your plan has a $3,000 deductible, you have met $2,200 of it, and coinsurance is 20 percent. The allowed amount for an in-network knee MRI is $900.
- Remaining deductible: $3,000 − $2,200 = $800.
- You pay the first $800 of the allowed amount: $800.
- Remaining allowed amount: $900 − $800 = $100, and 20 percent of that is $20.
- Your total share: $820; the plan pays $80.
If a nearby freestanding center quoted $600 cash and you pay cash, you would pay $600 instead of $820, but you would not move closer to your deductible unless your insurer credits it. Which is better depends on your expected spending later in the year.
Surprise bills and the No Surprises Act
For non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, federal law restricts out-of-network "surprise" bills from certain ancillary providers, including radiologists, in many cases. Freestanding imaging centers are not among the facility types covered by those specific protections, so confirm network status for both the facility and the reading radiologist before you go.
When to consult a professional
If a denial affects your treatment or the amount is large, ask your doctor's office to request a peer-to-peer review with the insurer, contact your state insurance department, or use a nonprofit patient advocate. Plan documents and state law control the details, and this guide cannot see your policy.
Frequently asked questions
Does Medicare pay for an MRI if my doctor orders it?
Part B generally covers it when it is medically necessary and the provider accepts Medicare. You usually pay the deductible and 20 percent of the approved amount.
What if my insurer denies prior authorization?
Ask for the written denial, ask your doctor to submit more clinical information or request a peer-to-peer call, and file an appeal by the deadline. You can also ask your state insurance department for help.
Do I need a referral for an MRI?
Most plans and centers need a clinician's order. HMO plans may also require a referral from your primary care doctor.
Can I use my HSA for the part I owe?
Generally yes, because a diagnostic MRI is a qualified medical expense. Keep the bill and the order.
Sources
- Medicare.gov — Part B coverage, costs and appeals
- Centers for Medicare & Medicaid Services — No Surprises Act and coverage rules
- HealthCare.gov — plan terms, out-of-pocket maximums and appeals
- IRS — HSA and FSA qualified medical expenses
