What “Medically Necessary” Means and How It Affects Your Medicare Coverage
This article was updated on: 07/28/2015
Medicare normally covers services deemed medically necessary. According to Medicare.gov, “medically necessary” is defined as “health-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” In any of those circumstances, if your condition produces debilitating symptoms or side effects, then it is also considered medically necessary to treat those.
Services considered medically necessary
What might this mean for you as a beneficiary? According to the above definition, Medicare covers services that it views as medically necessary to diagnose or treat your health condition. Services must also meet criteria supplied by national coverage determinations and local coverage determinations. These determinations are decided by the federal government (for the national level) and private Medicare contractors (for the local level), to determine whether or not Medicare will pay for a specific item or service. Medicare plans also use this criteria to determine whether additional rules, such as prior authorization, may apply to a given health-care service or supply. For example, if you need a hip-replacement surgery, your Medicare plan will use national or local coverage determinations to decide whether your surgery is medically necessary before authorizing it.
Services that are not considered medically necessary
Services that aren’t deemed medically necessary are not covered by Original Medicare, Part A and Part B. It’s possible that some of these services may be covered by a Medicare Advantage plan, but that depends on your specific plan benefits. Non-medically necessary services according to CMS include, but may not be limited to, the following:
- Times where your hospital service surpasses the Medicare-approved stay length
- Physical therapy treatment that surpasses Medicare’s usage limit
- Hospital-administered treatment that could have been delivered in a lower-cost setting
- Prescription of drugs to treat fertility, sexual or erectile dysfunction, weight loss or weight gain, and cosmetic purposes
Exceptions to the medically necessary requirement
The following procedures are covered by Medicare if you meet the eligibility criteria for the health-care service. Most of these services are covered under Medicare Part B. If you have a Medicare Advantage plan, also called Medicare Part C, then these services are covered under that plan, as Medicare Advantage plans must cover everything under Part A and Part B.
Covered preventive services include:
- Annual ‘Wellness’ visit
- Initial preventive physical examination (also known as the ‘Welcome to Medicare Preventive Visit’)
- Bone mass measurements are covered once every 24 months (or more frequently if medically necessary) if your doctor or health-care provider orders it. You must have Medicare Part B, be at risk for osteoporosis, and meet one or more of the following health 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.
- Clinical breast examinations
- Cardiovascular disease screenings
- Counseling to prevent tobacco use for asymptomatic beneficiaries
- Diabetes screening tests
- Diabetes self-management training (for beneficiaries diagnosed with diabetes)
- Glaucoma screenings are covered for all beneficiaries with Medicare Part B who have a high risk for glaucoma. Factors that put you at high risk for glaucoma include having diabetes; having a family history of glaucoma; being African American and age 50 or older; and being Hispanic American and age 65 or older.
- Human Immunodeficiency Virus (HIV) screenings
- Intensive behavioral therapy for cardiovascular disease
- Intensive behavioral therapy for obesity is covered for all beneficiaries with Medicare Part B who have a body mass index (BMI) of 30 or higher.
- Mammograms are covered for women with Medicare Part B who are 40 or older; one baseline mammogram is covered for women with Part B between 35 to 39 years old.
- Medical nutrition therapy (for certain beneficiaries diagnosed with diabetes, kidney disease, have received a kidney transplant within the last three years, or have been referred by their doctor)
- Pap tests and pelvic examinations are covered for all women every 24 months and once every 12 months for women at high risk for cervical or vaginal cancer; Pap tests are also covered for women of childbearing age who have had an abnormal Pap test in the past 36 months.
- Prostate cancer screenings are covered for all men with Medicare Part B over age 50, starting the day after their 50th birthday.
- Screenings for depression
- Screenings and behavioral counseling interventions in primary care to reduce alcohol misuse
- Screenings for sexually transmitted infections (STI) are covered if you have Medicare Part B and are pregnant. You may also be covered if you have a higher risk for getting an STI at the time the screenings are ordered by your primary-care doctor.
- High-intensity behavioral counseling to prevent sexually transmitted infections is covered for sexually active individuals with a higher risk for getting a STI.
- Certain vaccines are covered, including:
- Flu shots are covered for all beneficiaries with Medicare Part B; Medicare covers one influenza vaccine per flu season.
- Hepatitis B shots are covered for beneficiaries with Medicare Part B who have a high or medium risk for getting hepatitis B. Some conditions, such as hemophilia, end-stage renal disease, and diabetes, may increase your risk for hepatitis B.
- Pneumococcal shots are covered for all beneficiaries with Medicare Part B; Medicare also covers a different, second pneumococcal shot given 11 months after the first pneumococcal vaccine.
- Ultrasound screening for abdominal aortic aneurysm is covered one time if you have a referral for it from your doctor. You must have Medicare Part B and meet one of the criteria that put you at risk for an abdominal aortic aneurysm: You’re eligible for this screening if you have a family history for the condition or if you’re a male age 65 to 75 who has smoked at least 100 cigarettes over your lifetime.
For a more information about supplies and services that are covered and excluded by Medicare, see the CMS publication “Items and Services That Are Not Covered Under the Medicare Program.”
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