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What Does Medically Necessary Mean in Medicare?


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“Medically necessary” is a standard that Medicare uses when deciding whether to cover a health-care service or item. This applies to everything from flu shots and preventive screenings, to kidney dialysis and wheelchairs. But what does this phrase really mean, and how does it affect you as a beneficiary?

Medicare’s definition of “medically necessary”

According to Medicare.gov, health-care services or supplies are “medically necessary” if they:

  • Are needed to diagnose or treat an illness or injury, condition, disease (or its symptoms).
  • Meet accepted medical standards.

Under this definition, certain services, medical equipment, and medications aren’t considered medically necessary and aren’t covered by Medicare:

  • Routine dental services, including dental exams, cleanings, fillings, and extractions
  • Routine vision services, including eye exams, eyeglasses, or contacts
  • Most hearing services, including non-diagnostic exams and hearing aids
  • Acupuncture
  • Vitamins
  • Over-the-counter medications

In some cases, Medicare may cover a service it normally doesn’t cover if it’s related to a covered procedure. For example, while most routine dental care isn’t normally covered, Medicare will cover a dental exam that is part of a pre-op exam if you’re about to get a kidney transplant or heart valve replacement. Medicare will also pay for tooth extractions that are needed to prepare your mouth for radiation treatment of neoplastic disease (for example, cancer involving the mouth or jaw).

As another example, routine vision services aren’t covered by Medicare, and you’ll normally pay the full cost for eye exams, contact lenses, and eyeglasses. However, if you get cataract surgery to implant an intraocular lens, Medicare helps cover the cost of corrective lenses (either one pair of eyeglasses or one set of contact lenses). You’ll pay 20% of the Medicare-approved amount, and the Medicare Part B deductible applies.

Medically necessary services under Original Medicare

Original Medicare is the government-run health-care program, made up of Medicare Part A (hospital insurance) and Part B (medical insurance). Medicare Part A covers medically necessary services and treatment you get in an inpatient setting, including:

  • Hospital care
  • Skilled nursing facility care*
  • Hospice care
  • Home health services

*Medicare covers nursing care when non-skilled, custodial care (such as help with daily tasks like bathing or eating) isn’t the only care you need. This coverage is generally for a limited period of time.

Medicare Part B covers medically necessary services and care you might need in an outpatient setting, such as:

  • Wellness exams
  • Preventive screenings
  • Certain vaccinations, including flu shots
  • X-rays
  • Lab tests
  • Mental health services
  • Certain prescription drugs that you don’t give yourself (such as intravenous drugs)

Medically necessary services under Medicare Advantage plans

The Medicare Advantage (also known as Medicare Part C) program is another option you may have as a Medicare beneficiary. Medicare Advantage plans are available through private insurance companies that contract with Medicare and are another way to get your Medicare Part A and Part B coverage.

By law, Medicare Advantage plans are required to cover at least the same level of health coverage as Original Medicare, including all medically necessary services under Medicare Part A and Part B (with the exception of hospice care). However, individual Medicare Advantage plans also have the flexibility to cover extra services that aren’t considered medically necessary under Original Medicare; this may include benefits like routine vision or dental, health wellness programs, hearing services, or prescription drugs covered under Medicare Part D.

Medicare Advantage plans may vary quite a bit when it comes to specific benefits they cover, so always check with the individual plan if you’re interested in a particular service.

If you’d like help finding Medicare plan options that cover specific health-care services, an eHealth licensed insurance agent can help you look for coverage that fits your specific needs and budget. Just pick up the phone and call to speak with a licensed insurance agent, or use our plan finder tool on this page to browse plan options in your area.

What if Medicare doesn’t cover a service I think is medically necessary?

In most cases, if Medicare decides that your service or equipment doesn’t meet its definition of medically necessary, you won’t be covered, and you’ll have to pay for the full cost out of pocket.

However, you have a few options if Medicare doesn’t cover a health-care service or item that you think you need.

Requesting an advance coverage decision

If you aren’t sure whether a service or item you may need is covered, you can ask Medicare for an advance coverage decision, which is a document from Medicare letting you know whether a particular service or equipment is covered and what your costs may be. How you do this depends on whether you have Original Medicare or a Medicare Advantage plan.

If you’re enrolled in Original Medicare and your doctor, other health-care provider, or supplier believes that Medicare probably (or certainly) will not cover a particular service or supply, he or she may give you an “Advance Beneficiary Notice of Noncoverage,” which is a notice stating what Medicare will not cover and the reasons for noncoverage, as well as what your estimated costs will be. From there, you can decide if you still want to continue with getting the procedure or equipment, given that you may have to pay certain costs, or the entire cost in some cases, out of pocket. Note that an Advance Beneficiary Notice of Noncoverage is not required for services or items that are never covered by Medicare.

If you’re enrolled in Medicare Part C, you can request an advance coverage decision from your Medicare Advantage plan. This is a notice from your Medicare Advantage plan that lets you know whether a specific service is covered and what your costs may be.

Appealing a noncoverage decision

If you’ve already received a service or equipment and Medicare has denied your claim, you have a right to appeal the decision. The appeals process works differently depending on whether you have Original Medicare or a Medicare Advantage plan. You also have a right to ask for an expedited appeal if waiting for a standard decision could endanger your health. For more information, take a look at this online publication on the Medicare appeals process here.

This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

 

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