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What Does 'Medically Necessary' Mean?

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What Does 'Medically Necessary' Mean?

Monday, February 5, 2018 7:36 AM

 Medically Necessary

If you are a Medicare beneficiary, you may have come across the term, “medically necessary” to refer to services covered by Medicare. But what does it mean?

According to HealthCare.gov, medically necessary services are defined as “health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms – and that meet accepted standards of medicine.”

The Centers for Medicare & Medicaid Services (CMS) provides further detail regarding medically necessary services as they apply to your Medicare coverage. According to CMS, medically necessary services or supplies: 

  • Are proper and needed for the diagnosis or treatment of your medical condition.
  • Are provided for the diagnosis, direct care, and treatment of your medical condition.
  • Meet the standards of good medical practice in the local area and are not mainly for the convenience of you or your doctor.

Determining Medical Necessity

No one wants to hear that a service is “not medically necessary.” To find out if Medicare covers what you need, talk to your doctor or other health care provider about why certain services or supplies are necessary, and ask if Medicare will cover them. If you have a private insurance plan, such as a Medicare Advantage or Medicare Supplement Plan, talk to your insurer about your coverage. If services and supplies you need are not covered under your current plan, call a Medicare.org licensed sales agent at (888) 815-3313 - TTY 711 to learn about making changes to your coverage during the Annual Enrollment Period (AEP) from October 15th – December 7th, or during other times of the year when you may be eligible for a Special Enrollment Period. You can also visit the official U.S. government site for Medicare to find out if your test, item, or service is covered

Not Medically Necessary Services and Supplies

The Medicare program covers many services and supplies that are needed to diagnose or treat medical conditions. Most beneficiaries do not have problems receiving covered services and treatments they need for their health. However, it is important to understand the types of services and supplies that are considered “not medically reasonable and necessary.”

According to CMS, some services not considered medically necessary may include:

  • Services given in a hospital that, based on the beneficiary’s condition, could have been furnished in a lower-cost setting
  • Hospital services that exceed Medicare length of stay limitations
  • Evaluation and management services that exceed those considered medically reasonable and necessary
  • Therapy or diagnostic procedures that exceed Medicare usage limits
  • Screening tests, examinations, and therapies for which the beneficiary has no symptoms or documented conditions, except for certain screening tests, examinations, and therapies
  • Services not called for based on the diagnosis of the beneficiary (for example, acupuncture and transcendental meditation)
  • Items and services administered to a beneficiary for causing or aiding in causing death

Advance Beneficiary Notice of Noncoverage

If you need something that is usually covered, but your doctor, health care provider, or supplier thinks that Medicare will not cover it, you will have to read and sign a notice called an "Advance Beneficiary Notice of Noncoverage" (ABN), and will serve as your acceptance that you may have to pay for the item, service, or supply.

Certificate of Medical Necessity

A Certificate of Medical Necessity (CMN) or a DME Information Form (DIF) (also called a letter of medical necessity), is a form needed to help document the medical necessity and other coverage criteria for selected durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

Questions about Medicare? Medicare.org’s information and resources can help make it easy to find the quality and affordable Medicare plan that’s right for you. We offer free, accurate comparisons for Medicare Advantage (Part C), Medicare Supplement (Medigap), and Medicare Prescription Drug (Part D) Plans. 

Get an online quote for Medicare plans that fit your health care needs today! Or call (888) 815-3313 - TTY 711 to get answers and guidance over the phone from an experienced licensed sales agent.

Related Information:

Original Medicare or Medicare Advantage? 4 Questions to Help You Choose

Can You Laminate Your Medicare Card?

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Last Revised 11/15/2017