“Medically Necessary” Defined
Updated for October, 2021
A “medical necessity” can be an overarching term to describe something that is absolutely needed to help someone survive or get better. In terms of Medicare—and healthcare in general—“medically necessary” is an important term when determining what is covered, or not covered, by your plan.
Given that this concept is so important that your Medicare coverage relies on it, what does it mean? What is medically necessary and what isn’t? What happens when you need something that doesn’t fit this term? We’ve covered all of these concerns, and we’ll start with what “medically necessary” actually means.
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What Does “Medically Necessary” Mean?
According to the Medicare glossary, medically necessary refers to:
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
Anything deemed “medically necessary” is vital to the Medicare process and coverage because Medicare only helps pay for what is absolutely needed to help treat an injury, illness, or other medical condition.
This means that the deductible and premiums you pay for treatment that falls under Part B (as well as Part C, which covers what parts A and B do, and Part D, which covers prescription drugs) will only cover the services or equipment used to treat your condition. If a service or piece of equipment is not used to treat your condition, you will most likely have to pay for it completely out of pocket.
Medicare covers more than these medically necessary services, though. Parts A and B also cover “preventative services,” which you could argue are medically necessary as well because they could help “diagnose or treat an illness, injury, condition, disease, or its symptoms.”
These services include:
- An annual wellness visit
- Diabetes screenings
- Mental health screenings
- STI screenings
- Bone density screenings
- Breast examinations
For the sake of this article, we’ll focus on the services that are “medically necessary,” but know that preventative services are covered by Medicare, too. Before we get into the remaining “medically necessary” coverage, let’s discuss how treatment or equipment is declared medically necessary in the first place.
When it comes to equipment, sometimes not every part of the equipment is covered by Medicare.
What Isn’t “Medically Necessary”?
Services that aren’t deemed “medically necessary” include everything Medicare won’t cover. In a CMS pamphlet that lists everything not covered under Medicare, the primary category is “services and supplies that are not medically reasonable and necessary.”
These services include:
- Hospital services that could be administered in a “lower-cost setting” like the person’s home or a nursing home.
- Excessive hospital stays beyond what is deemed “medically necessary.” As mentioned, Medicare will pay for part of your hospital stays up to 90 days at a time, and then they will give you 60 “lifetime reserve days.” Beyond that, Medicare doesn’t deem your stay “medically necessary” (in most cases).
- Any screening, test, and therapy unrelated to a condition or diagnosis that does not have any symptoms. (You are allowed one wellness check up every year, though.)
- Excessive therapy
- Excessive procedures used to diagnose your condition
- Procedures or accessories used to assist or cause death, also known as assisted suicide, which is allowed in some states (but not covered by Medicare).
When it comes to equipment, sometimes not every part of the equipment is covered by Medicare. For example, lift chairs—devices that help people with severe arthritis stand up and sit down— are medically necessary devices, but only the contraption that helps the person get up and lay down is covered.
This means that the seat, fabric, and cushions aren’t covered. In this case, Medicare will cover 80 percent of the cost (the normal rate for Part B services) of the device, and you will pay out of pocket for the rest of it. So, even when a contraception or equipment is medically necessary, you should make sure that its accessories are also covered by Medicare.
There are some prescriptions that aren’t medically necessary either. These include weight loss pills, fertility pills, and drugs that treat erectile dysfunction.
What Happens When I Need Something That Isn’t “Medically Necessary?”
If you need a service or piece of equipment that isn’t covered by Medicare, your provider will most likely ask you to fill out a form known as Advance Beneficiary Notice of Noncoverage. Signing this form means that you accept that the particular service won’t be covered by Medicare and that you will have to pay the entirety of the cost.
However, signing this form doesn’t mean that your service definitely will not be covered by Medicare, but rather that the provider believes it won’t be and is covering themselves from any liability. You still may be able to make the case to Medicare that the service is “medically necessary.”
If you have any other questions regarding what is or isn’t deemed medically necessary by Medicare, contact your local Social Security Administration office or have a conversation with your medical provider.