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What Does Medically Necessary Mean


Medically necessary refers to health services or supplies that you need for treatment. You may feel that your condition warrants specific care, but your insurance may disagree. Below we’ll discuss what qualifies as necessary and what doesn’t meet the requirement. Then, you can better navigate your Medicare.

What Does Medically Necessary Mean?

During your Medicare journey, you may come across the term “medically necessary.” What exactly does “necessary” mean by Medicare’s standards? Aren’t all health care services “necessary”? The official definition of medically necessary is health care required to treat or diagnose.

Criteria Used to Determine Medical Necessity

Your insurance may have rules to gauge whether a service is necessary. The company can give you details about services. Also, services that have coverage are generally available online. A vital thing to look for is the limits on how often you can obtain treatment. Further, insurance may place caps on the number of times they completely cover scans or x-rays.

While insurance may cover the first set of x-rays, they may not pay for the second. So, the term “covered” is a loose term. Other cases may provide full coverage and full reimbursement. Alternative treatment options may be available. Also, your doctor can offer alternatives to see if you might get full coverage.

Speak with your doctor first to come up with a plan. Make sure you verify if your policy requires the use of in-network doctors. You may not have coverage out of the network, or you may have high costs.

Defining “Medically Necessary”

Medical necessity is the procedure, test, or service that a doctor requires following a diagnosis. Anything “necessary” means Medicare will pay to treat an injury or illness. But, most procedures and medical equipment are necessary. You may run into a service or supply that needs approval from your doctor.

Here are some examples of necessary services:

  • Hospice care
  • Preventive care
  • Hospital care
  • Health screenings
  • Labs
  • X-rays
  • Vaccinations
  • Durable medical equipment
  • Ambulance services
  • Physician visits

Non-Necessary Medical Services and Devices

Medicare won’t cover all medical devices and services. Some specific services and supplies aren’t necessary.

Most times, these services include:

There may be instances Medicare covers services it wouldn’t cover if already covering a relatable procedure.

How to Get Medicare to Pay for Necessary Treatment Not Covered by Medicare

Medicare may determine that services aren’t necessary. Your health services may not have coverage because of these determinations. If you face non-covered treatments, you’ll cover the full costs. Your doctor can provide you with an Advance Beneficiary Notice of Noncoverage. The notice declares that Medicare won’t cover specific treatments. It also states why they won’t include the services.

The notice will also state the costs. You can choose if you’d like to continue paying for services. If you enroll in Part C, you’ll be able to ask for an advance coverage decision from your health plan.

There may be instances in which you may have already undergone treatments. If you find yourself in this predicament, you can choose to go through the appeals process.

Depending on which forms of coverage you have, your procedure may be different. Expedited appeals are always options for life-threatening conditions since quick decisions are necessary.

What is Medically Necessary Under a Medicare Advantage Plan?

Advantage plans can cover services that aren’t necessary, such as dental, vision, or hearing. But, an Advantage plan can determine a service isn’t essential or chose not to pay a claim that is out of network. As long as you stay in-network, the Advantage plan must follow CMS Guidelines. Further, the policy must provide extra benefits. Many Advantage plans cover things like OTC medications and supplies. Some Advantage plans will even cover long-term care and at-home services.

The things that are “necessary” are dependant on the plan you select. You may want a document that advises you which services have coverage. But, if you’re wanting to find out your exact coverage, you can ask for an Advance Coverage decision.

If your doctor thinks that Medicare won’t cover, the doctor can provide an “Advance Beneficiary Notice of Noncoverage.” This notice states what Medicare won’t cover and explains noncoverage. Also, this provides you with an estimate for costs.

Who Determines Medical Necessity?

Some cases say the doctor is the sole responsibility for determining medical necessity. Others say “necessity” is a contract term that a doctor must prove a service is appropriate. If the doctor submits documentation to show necessity, in some cases, Medicare covers, but, sometimes, services don’t have coverage no matter how necessary.

How does Medicare determine if a service is medically necessary?

Medicare considers a health service necessary if your condition meets all medical standards. The services need to diagnose and treat the health condition or injury. Medicare makes its determinations on state and federal laws. Local coverage makes determinations through individual state companies that process claims.

FAQs

What is a Medicare medical necessity denial?
For the most part, Medicare medical necessity denial happens with a Part C plan. It’s a denial of an otherwise covered service that the plan considers unreasonable and unnecessary.
How do you handle medical denials?
You can file an appeal within 120 days of getting your Medicare Summary Notice that notifies you of the denial.
How do you prove medical necessity?
Services must be necessary to make a diagnosis or to treat an illness for coverage to be possible.

How to Find Out if it's Medically Necessary

Medigap must follow all state and federal rules. Further, if Medicare approves a service, the Medigap company must also agree. Do you find all the rules and regulations confusing? Do you worry about prior authorization? Are you trying to find the best policy for you?

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Lindsay Engle

Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

2 thoughts on “What Does Medically Necessary Mean

  1. Hello Lindsey. Due to extensive radiation last year for stage 4 cancer tumors in my spine, my lower lymphatic system was deeply damaged. I have been going to hyperbaric treatment to help restore and recreate new vessels, and have found a medical massage specialist who can offer lymphodema massage for the fluids causing continual swelling in my legs and feet. My physician felt this would be of great benefit for my health, but this type of therapist is not covered by my insurance. They will cover is at out of network level, so my question is, will the QMB coverage I also have, cover the balance? Thank you~

    1. Hi Virginia! Unfortunately, I don’t think QMB will cover massage therapy since Medicare doesn’t cover it. I would contact your local Medicaid office since they handle your QMB to find out for sure though. Good luck!

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