What Does Medically Necessary Mean?

When you visit the doctor or receive medical services, it’s often covered by your Medicare plan, at least partially. This is because much of the medical care you receive is considered “medically necessary.” This is a term that comes up a lot when you learn more about Medicare, and for good reason. It can greatly influence your coverage. But what exactly is considered medically necessary, and, more importantly, why? Possibly most importantly, how can something’s medical necessity affect your Medicare coverage?

How It Influences Coverage

Let’s start with how your coverage is affected, since it’s likely the concern most central to your thoughts right now. Medicare will generally only cover a service or item if it is medically necessary or preventive. Otherwise, you’ll be on the hook for out-of-pocket costs for whatever it is. For the most part, if something is regularly covered by Original Medicare (Part A or Part B), it’s because it’s considered medically necessary. That said, if you want to use a service that would normally be covered, but you want to use it when it isn’t medically necessary, Medicare likely won’t cover it. At this step, you may be able to appeal this coverage decision to try and get the service covered.

Medical necessity can also influence your coverage for services and items that aren’t normally covered.

While medical necessity can mean something that is normally covered isn’t in certain circumstances, it can also influence your coverage for services and items that aren’t normally covered. For example, Medicare will usually cover cataract surgery if it’s medically necessary.

The same is true for durable medical equipment or even specific prescription drugs that otherwise wouldn’t be covered. Medicare may also require medical necessity to cover inpatient care or home health care.

You may be wondering why the Medicare program is so strict on what is medically necessary and what is covered, but it’s for a very good reason. Requiring a service to be medically necessary cuts down on Medicare abuse, referring to the billing of unnecessary services and items. While this may seem arbitrary to some, it’s important to control costs somewhat so that the program itself can stay afloat and cover seniors in the long term.

What is Medical Necessity?

Okay, so now that we know how medical necessity changes your Medicare coverage, let’s talk about what medically necessary is exactly. After all, if it can change your coverage, it’d be good to understand what it is. Medically necessary for Medicare is defined as:

Any health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms. These must meet the accepted standards of medicine.

That’s a pretty general description of the term, so let’s dig a little deeper into what it means exactly. So, in order to be medically necessary, a service or supply must be two things. First, it must be directly tied to the diagnosis or treatment of a specific medical condition. This is why preventive services aren’t technically medically necessary (though still very important) and Medicare distinguishes between the two. Preventive services, like diabetes screenings or tobacco cessation counseling, seek to stop you from developing a condition, so it’s not related to the diagnosis or treatment of any conditions.

By the same token, routine vision, hearing, and dental care aren’t considered medically necessary.

The second requirement is that it meets the basic standards of the medicine. This simply means that the service or supply is recognized as effective and safe by the relevant medical community and experts. This effectiveness and safety should be backed up by credible, peer-reviewed research. So, while your grandson may think Teddy makes his stomach feel better when it’s upset, he likely doesn’t have the research to verify that Teddy would be an effective treatment for gastroesophageal reflux disease. On a more serious note, it’s why Medicare more often than not won’t cover alternative medicine or experimental medicine, such as reiki or dietary supplements.

How is Medical Necessity Determined?

When it comes to whether something is considered medically necessary or not, a good rule of thumb is if Medicare covers it regularly, you should be in the clear for coverage. The Centers for Medicare & Medicaid Services (CMS) gives a few examples of services and supplies Medicare doesn’t cover because they’re considered unreasonable or unnecessary. Among these are excessive services based on the diagnosis, evaluation or management services considered to go beyond what’s considered medically reasonable or needed, hospital stays exceeding the length-of-stay limit, and items and services that would facilitate assisted suicide, to name a few.

If you’re ever unsure if something will be covered due to necessity, you can always check with your doctor to ensure they’ve ordered or approved it.

What’s important is that a doctor should order or prescribe it, declaring it medically necessary. In some cases, serviced that aren’t normally covered (like the earlier mentioned cataract surgery) can be also covered if they’re declared medically necessary by a doctor. If you’re ever unsure if something will be covered due to necessity, you can always check with your doctor to ensure they’ve ordered or approved it.

For other services or supplies, like durable medical equipment in Original Medicare, you may need prior authorization, which is essentially Medicare validating that the thing is medically necessary before you receive the service or item so that it’s covered.

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Medically necessary is a term you hear a lot of when you deal with medical care, whether that’s from the service provider side, the service user side, or as a writer. It’s one of the key designations that points to whether something will likely be covered or not. Given its importance to what you’ll be paying for your health care, understanding what it is and why can be pretty important!