What does “medically necessary” mean?

If you’ve researched Medicare, chances are high that you’ve come across the phrase “medically necessary.” How the term medically necessary affects your Medicare coverage? The context usually involves whether or not Medicare will pay for a given treatment or medical service. That makes it important to understand how the federal government views the term and how it will affect your ability to obtain assistance when it comes to pricey procedures.

Medicare’s official website defines “medically necessary” as “health care services or supplies needed to prevent, diagnose, or treat an injury, illness, condition, disease, or its symptoms and that meet accepted standards of medicine.” This definition may also be expanded to include side effects of a given condition on a case-by-case basis.

How the term medically necessary affects your Medicare coverage

In addition to meeting Medicare’s criteria for medical necessity, a given procedure or treatment must meet national and local coverage criteria. The federal government, as well as local Medicare contractors, ultimately decide if Medicare will pay for a given service. The national and local criteria also help determine whether other factors like prior authorization might apply to your particular situation. In plain language, this means that Medicare will use local and national coverage determinations to decide whether or not a surgery that you are requesting is medically necessary.

So what happens when Medicare deems an aspect of your treatment as medically unnecessary? Typically the treatment in question will not be covered under Original Medicare Part A or Part B. It’s possible that a Medicare Advantage plan may cover the treatment you need, but you’ll need to consult with the plan provider to determine the specific parameters and conditions that apply. Some examples of services that fall outside of Medicare’s “medically necessary” definition include hospital stay-length overages, physical therapy usage limit overages, hospital treatments that could have been administered on an outpatient or lower-cost basis, and prescription drugs designed to treat sexual dysfunction, weight management, fertility, or cosmetics.

Exceptions to “medically necessary” requirement

There are some exceptions to the “medically necessary” requirement when it comes to preventive services. Most of these procedures will in fact be covered under Medicare Part B as long as you meet the service’s individual eligibility requirements. Additionally, some of these services may be covered under Medicare Advantage (sometimes referred to as Medicare Part C).

  • Annual wellness checkup
  • Welcome to Medicare Preventive Visit
  • Bone mass measurements every 24 months if ordered by your physician, if you are at risk for osteoporosis, and if you meet or more of the following conditions: Be a woman who is found by her doctor to be estrogen deficient and at risk for osteoporosis; be a person diagnosed with primary hyperparathyroidism; be a person whose X-rays indicate potential vertebral fractures, osteopenia, or osteoporosis; be a person taking steroid-type medications or prednisone or be planning to start this treatment; or be a person on osteoporosis drug therapy who is being monitored to see if the drug therapy is effective.
  • Colonoscopy
  • Clinical breast exam
  • Cardiovascular disease screening
  • Preventive tobacco use counseling
  • Diabetes screening
  • Diabetes self-management training
  • Glaucoma screenings for Part B beneficiaries at high risk
  • HIV screenings
  • Behavioral therapy for cardiovascular disease
  • Behavioral therapy for obesity for Part B beneficiaries with BMI of 30 or higher
  • Mammograms for women over 40
  • Medical nutrition therapy
  • Pap tests and pelvic examinations for women at high risk for cervical or vaginal cancer
  • Prostate cancer screenings for men over 50
  • Depression screenings
  • Screenings and behavioral intervention for alcohol misuse
  • Screenings for sexually transmitted infections for pregnant women
  • Behavioral counseling for sexually active individuals with high risk of transmitted infections
  • Flu vaccines including: all beneficiaries with Part B, Hepatitis B shots for those with medium to high risk, pneumococcal shots for all Part B beneficiaries
  • Ultrasound screening for abdominal aortic aneurysm if you have a doctor referral

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