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.
Medicare uses certain criteria from National and Local providers to deem certain procedures either Medically Necessary or Non Medically Necessary. Contrary to popular belief, Medicare is NOT trying to find a reason NOT to cover something. The reverse couldn’t be more true. What they are doing is trying their best to weed out the abuse of Medicare by PROVIDERS, not Patients. Some things happen that just shouldn’t, and Most if not all of the Non Medically Necessary items are just things that the taxpayer should not have to pick up the bill for. Here are some examples:
- 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
If you have Original Medicare and a supplement (or Medigap coverage) your supplement has to pay its part if Medicare deems a procedure Medically Necessary. On the contrary, if Medicare doesn’t pay because a procedure is Non Medically Necessary, your supplement will not either.
The important thing to consider here is the Provider. No matter the procedure, or reason for the office visit, Providers are well versed in the difference of Medically Necessary versus Non. It is VERY important to ask questions to your doctor about procedures and how you insurance will cover it. The Provider can tell you right up front if Medicare will approve the claim or not. Or, at least they should. Don’t be afraid to ask questions of your provider. Talk to the insurance biller in the Doctors office if you need to. If for some reason your Doctors office or hospital cannot tell you if your recommended procedure is Medically Necessary, you should not agree to the procedure until you find out whether it is or isn’t.
A vast majority of the time, Medically Necessary just means common sense. If your Provider is wanting to perform a Non Medically Necessary procedure, I would certainly consider a 2nd or 3rd opinion.