According to Medicare, medically necessary services are defined as: “Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.”
There are two primary ways to find out if Medicare covers a service you may need.
- Talk to your doctor or other health care provider about the services or supplies you think you need and ask if Medicare will cover them. There may be situations when you feel you need something that Medicare usually covers, but your doctor says they may not cover it in your specific situation. If that is the case, the doctor may have you read and sign a notice that says you may have to pay for the item, service, or supply in question if Medicare does not cover it.
- Visit this Medicare website to lookup a specific test, item, or service you need and see if Medicare covers it.
In general, Medicare decides if things are medically necessary based on three main factors:
- Federal and state laws.
- National coverage decisions made by Medicare about whether something is covered.
- Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
