When Does Medicare Consider a Service Medically Necessary?

Published 12/29/2020

In many of our articles, we speak to how Medicare pays only when a service is "medically necessary," also known as "reasonable and necessary." That can be hard for a patient to determine. This article focuses on how Medicare determines ‘medical necessity’ in order to pay or deny a claim.

"Reasonable (Medically) and Necessary" describes services that are:

  • Safe and effective (Not experimental or investigational)
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Provided within accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member
    • Performed in a setting appropriate to the patient’s medical needs and condition
    • Ordered and provided by qualified personnel
    • Meeting, but does not exceeding, the patient’s medical need

Here are some examples of when Medicare pays, as long as the services are proven by the documentation supplied by your doctor to support medical necessity:

  • Pneumococcal, influenza and hepatitis B vaccines are covered if they are reasonable and necessary for the prevention of illness
  • Screen mammography is covered if it is within frequency limits and meets quality standards
  • Screening pap smears and screening pelvic exam are covered if they are within frequency limits
  • Prostate cancer screening tests are covered if within frequency limits
  • Colorectal cancer screening tests are covered if within frequency limits
  • One pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens

To learn about frequency limits for the screening tests, please see Preventive and Screening Services CMS web page. 

If you have a question about the medical necessity of a claim, you may call our Beneficiary Contact Center at 800-833-4455, or for the hearing impaired, call TTY/TDD at 877-566-3572. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. until 7 p.m. ET. We also encourage you to visit our Facebook page at www.Facebook.com/MyRRMedicare.

Was this article helpful?