What Does ‘Medically Necessary’ Mean for Medicare Coverage?
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Medicare covers a lot of services, but only when they’re medically necessary.
Medically necessary services are “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine,” according to the Centers for Medicare & Medicaid Services, or CMS.
You can look services up online or talk to your health care providers to find out whether and how Medicare covers them. If Medicare won’t cover a service that you or your doctor thinks is necessary, you can appeal that decision.
How do I know whether a service will be covered?
You can check how Medicare covers items and services online at medicare.gov/coverage.
If your health care provider thinks that a service you request won’t be covered by Medicare, they might give you notice with a Medicare Advance Beneficiary Notice of Non-Coverage, or ABN.
ABNs are provided only to people with Original Medicare (Part A and/or Part B). If you have Medicare Advantage, you might get a different notice or form.
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What makes a service medically necessary?
Medicare’s decisions about medical necessity happen at three levels, from most general to most specific:
Laws. Federal and state laws can set requirements for what’s covered.
National coverage determinations, or NCDs. Using a public, evidence-based process, Medicare decides whether and how a certain item or service is covered for the whole country.
Local coverage determinations, or LCDs. If a particular item or service isn’t included in relevant laws or NCDs, Medicare contracts with local companies that make coverage decisions. LCDs don’t apply nationally — they’re geographically limited to certain areas according to Medicare’s contracts.
» MORE: 7 things Medicare doesn’t cover
What does ‘medically unreasonable and unnecessary’ mean?
Medicare doesn’t pay for “medically unreasonable and unnecessary services and supplies to diagnose and treat a Medicare patient’s condition,” according to CMS.
Here are a few examples of what CMS considers medically unreasonable and unnecessary:
Tests or therapies that aren’t related to a patient’s symptoms or conditions.
Getting more or longer services than necessary, such as staying in the hospital or continuing therapy too long.
Services provided at a hospital when they could have been provided in lower-cost settings.
Can I appeal if I’m denied based on medical necessity?
If a service or item is denied because it’s not medically necessary, you can appeal that decision.
You’ll receive a written notice that explains what was denied, the reasons for denial and how you can appeal. You then need to submit the necessary information before any appeal deadlines.
If your appeal is denied, it’s not necessarily the end of the road. You can escalate the appeal to a higher level. As with the original denial, the written notice you receive about a decision on your appeal will include instructions for your next steps.
