Billions Wasted: How Low-Value Medical Imaging is Draining Medicare—and What Can Be Done About It 

New evidence reveals that medical imaging is a significant contributor to one of Medicare’s most persistent problems: overspending on services that offer little to no clinical benefit. 

According to a recent cross-sectional study published in JAMA Health Forum on August 1, 2025, four of the five most frequently performed low-value services among Medicare beneficiaries are imaging-based. These include imaging for plantar fasciitis, headaches, syncope (fainting), and lower back pain—services widely flagged as unnecessary by clinical guidelines and expert consensus. 

The researchers, led by David D. Kim, PhD (University of Chicago), and A. Mark Fendrick, MD (University of Michigan), used a nationally representative 5% sample of fee-for-service Medicare claims from 2018 to 2020. Their findings shine a harsh light on persistent inefficiencies in the U.S. healthcare system. 

What Counts as “Low-Value” Imaging? 

Low-value care refers to medical services that provide minimal or no benefit to patients in specific clinical scenarios. The determination is based on authoritative sources like the Choosing Wisely campaign and recommendations from the U.S. Preventive Services Task Force. 

In the case of imaging, examples include: 

• Imaging for plantar fasciitis – unnecessary in the absence of red-flag symptoms. 

• CT or MRI for headache – discouraged when the headache lacks features suggestive of serious underlying pathology. 

• Imaging for syncope – not indicated when there’s no accompanying neurological sign. 

• Routine back imaging – usually unnecessary within the first six weeks of nonspecific low back pain. 

Despite widespread awareness of these guidelines, such tests remain common practice. 

Key Findings from the JAMA Health Forum Study 

• Imaging for plantar fasciitis topped the list, with a rate of 83.8 services per 100 Medicare beneficiaries. 

• Other high-volume imaging services included headache imaging (76/100) and syncope (72/100). 

• In total, 15 low-value imaging services accounted for $484 million in Medicare spending, or $584 million when including patient out-of-pocket costs. 

• Across all 47 low-value services examined in the study, Medicare spent approximately $3.6 billion annually, while patients bore an additional $800 million out-of-pocket. 

• The top 20 services represented 95% of the total spend on low-value care. 

• Imaging was overrepresented in frequency but accounted for a smaller portion of total dollars compared to other services like unnecessary COPD screenings. 

While not the most expensive services individually, the frequency of these imaging tests means they exert an outsized impact on Medicare’s budget. 

Why Does This Happen? 

Several systemic factors contribute to the overuse of low-value imaging: 

1. Defensive medicine – Physicians may order tests to avoid malpractice claims, even when clinical guidelines suggest restraint. 

2. Financial incentives – Fee-for-service payment models reward volume, not value. 

3. Patient expectations – Many patients equate thoroughness with quality, expecting imaging for reassurance. 

4. Workflow and technology – Electronic health record systems often make it easier to order tests than to justify their omission. 

5. Limited enforcement of guidelines – CMS and commercial payers issue policies, but provider compliance is uneven. 

The Role of Artificial Intelligence—and Its Pitfalls 

Ironically, some of the same forces driving unnecessary imaging are now being used to control it. 

AI-driven algorithms are increasingly being used by payers to detect patterns associated with wasteful care. For example, applications with certain risk flags—like outdated demographic data, multiple group affiliations, or previous denial history—are now more likely to be automatically denied. While this can prevent abuse, it also introduces new risks, such as false positives or gaming of coding rules. 

Kim and Fendrick caution that providers may re-code services to bypass filters—e.g., billing a head CT for a fall instead of for syncope—thus undermining payer attempts to reduce low-value care. The net result could be service substitution rather than true cost avoidance. 

Cascading Costs: The Hidden Impact 

The headline figures may actually understate the problem. The authors deliberately excluded the “cascading” costs that result when a low-value imaging test leads to further consultations, procedures, or even surgeries. A well-cited 2018 analysis by Schwartz et al. in Health Affairs found that for every $1 spent on unnecessary PSA screening, $6 was spent on downstream services in Medicare Advantage. 

If similar ratios apply to imaging, the real cost of low-value scans may be several-fold higher than the initial figure suggests. 

Can Prior Authorization Help—or Hurt? 

One proposed solution is more rigorous prior authorization. While this can reduce unnecessary services, it also risks delaying legitimate care or creating administrative burdens that disproportionately affect small practices and rural providers. 

There’s also limited evidence that current prior auth processes are applied uniformly or effectively. A 2022 AMA survey found that 88% of physicians described prior auth requirements as “sometimes” or “often” leading to treatment delays, and 34% said it had led to a serious adverse event in their patients. 

Policy Levers: What Can Be Done? 

Kim and Fendrick propose several reforms that could reduce the use of low-value imaging without jeopardizing patient outcomes: 

• Incentivize adherence to clinical guidelines, especially through value-based care arrangements. 

• Leverage data transparency—provide providers and patients with utilization metrics tied to value. 

• Modernize claims auditing to identify waste while minimizing disruption. 

• Fund education programs for both clinicians and patients about when imaging is (and isn’t) appropriate. 

• Reinvest savings into high-value services like preventive care, chronic disease management, or mental health. 

Cutting Waste Without Cutting Corners 

The JAMA Health Forum study serves as a stark reminder: America’s aging population and rising healthcare costs demand more disciplined use of medical resources. Eliminating low-value imaging services represents an achievable and evidence-backed path to cost containment—without sacrificing patient safety. 

Yet to be successful, reforms must go beyond cost-cutting. They must support clinical judgment, incentivize guideline adherence, and invest in the tools providers need to make better decisions at the point of care. 

Until then, millions of Americans may continue to receive unnecessary scans—not because they need them, but because the system is wired to deliver them. 

Sources: 

• Kim DD, Fendrick AM. “Prevalence and Spending on Low-Value Imaging Services Among Medicare Beneficiaries.” JAMA Health Forum. August 1, 2025. https://jamanetwork.com/journals/jama-health-forum 

• Choosing Wisely Campaign. Recommendations by Specialty. https://www.choosingwisely.org 

• Schwartz AL et al. “Low-value service use in Medicare Advantage.” Health Affairs. 2018. 

• American Medical Association. “2022 Prior Authorization Physician Survey.” https://www.ama-assn.org