For Medicare beneficiaries, you may have heard the term medically necessary a time or two. But what is it, and how does it impact your Medicare benefits? We’ll go over information you may need to know about how Medicare determines a medically necessary procedure or treatment.
What is Medically Necessary?
When Medicare deems a service medically necessary or not, they’re trying to determine if they should pay for the service or item. This could be anything from preventative screenings and flu shots to wheelchairs and kidney dialysis.
Medicare defines medically necessary as services or products that someone needs to treat or diagnose an injury, illness, disease, condition, or symptoms. Additionally, any services or products have to meet Medicare’s standards. So, Medicare can claim your products or services are medically necessary if:
- Your doctor uses these items to diagnose a medical condition
- Your doctor or medical facility provides these services or items for the direct care, diagnosis, or treatment of your illness or medical condition.
- They meet the good medical practice standards for your area.
- They aren’t primarily for you or your doctor’s convenience.
Medically Necessary Services Under Original Medicare
Original Medicare is a healthcare program run by the government, and it includes Part A and Part B. Part A is hospital insurance, and Part B is medical insurance. Medically necessary services and treatments under Medicare Part A include services and care you may receive under a physician’s orders in:
- Hospice care
- Hospital care
- Home health services
- Skilled nursing facility care
Medicare Part B deems certain outpatient services to be medically necessary, and they include:
- Certain vaccinations
- Preventive screenings
- Wellness exams
- Lab tests
- Some prescription drugs like injections or IV
Medically Necessary Services Under Medicare Advantage Plans
Medicare Advantage plans offer a host of medically necessary Medicare benefits as well. Medicare Advantage plans are required to include all of the same Part A and Part B benefits as Original Medicare, but many offer additional benefits. You can get a Medicare Advantage plan through private insurance companies that have contracts with Medicare.
Medicare Advantage plans come with an additional benefit of offering a higher degree of flexibility to what they consider medically necessary. This means they usually cover more services or products like dental, vision, hearing services, health wellness programs, and prescription drugs that Medicare Part D covers.
Since Medicare Advantage plans can vary when it comes to deciding medically necessary services, it’s best to ask your doctor and check with your plan. If you have a specific service in mind, ask them directly.
Medical Services and Supplies That Aren’t Medically Necessary
Although most Medicare beneficiaries don’t have a problem getting the services or supplies they need for their care, there are some services and supplies Medicare deemed not medically necessary. They won’t pay for them if you choose to get or use them. A few products or services Medicare won’t cover include:
- Hospital, outpatient, or doctor services from a facility that is not participating in Medicare and does not accept assignment
- Hospital services that go over Medicare’s limitation on the stay length
- Management and evaluation services that go beyond medically necessary qualifications
- Diagnostic procedures or therapy that go beyond usage limits set by Medicare
- Exams, screening tests, or therapy when the recipient doesn’t have any documented conditions or symptoms
- Services like acupuncture that are not medically necessary based on the diagnosis
- Services that are considered elective or purely cosmetic in nature.
If you’re not sure whether or not Medicare considers your services, procedures, or items medically necessary, contact your plan before you have the procedures and discuss your concerns with your physician.