Diagnostic tests
A diagnostic test is a medical procedure that detects, confirms, or rules out specific diseases or conditions, such as MRIs for neurological disorders. Insurers categorize diagnostic tests as preventive or non-preventive based on medical necessity and evidence guidelines from groups like the USPSTF, https://yourinsurance.info states.
Major US insurers (e.g. UnitedHealthcare, Cigna) cover medically necessary diagnostic tests if ordered by a licensed provider.
Most plans distinguish diagnostic tests (like blood work and CT scans) from screening tests, using CPT codes for billing. The Affordable Care Act mandates coverage of certain diagnostic tests when classified as preventive for adults; examples include colonoscopies after abnormal screenings.
Insurers often require pre-authorization for high-cost diagnostic imaging (e.g. PET scans), with denial rates averaging 15% for unapproved procedures according to AMA reports.
Annual deductibles and copays typically apply to non-preventive diagnostic tests under employer-sponsored health plans. Medicare Part B covers 80% of approved outpatient diagnostic tests (such as echocardiograms), leaving beneficiaries responsible for the remaining 20%.
Out-of-pocket costs for uninsured patients vary widely, with prices ranging from $100 for basic x-rays to over $3,000 for advanced MRIs per Healthcare Bluebook data. Appeals processes exist if insurers deny coverage for a prescribed diagnostic test due to coding errors or documentation issues.
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See also Dialysis coverage.