Definition of Medically Necessary

Calendar Icon Updated May 24, 2019
Medicare

“Medically necessary” is a term that insurers typically use to describe the health services that they will cover.

Medicare also uses this term and will only pay for services that it considers “medically necessary.” In cases where certain medical services aren’t deemed medically necessary under the program, then you must foot the bill yourself for the services—if you go ahead and get them.

Medicare’s official website defines “medically necessary” as services or supplies that are needed to “diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” But what does this really mean?

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In general, services or items are medically necessary if they are:

  • proper and needed to treat or diagnose your medical condition, illness, injury, or disease
  • provided so that the doctor can diagnose, as well as provide direct care and treatment of the medical condition that you have
  • in line with the current standards of good medical practice (and are not just for the convenience of the patient or the health care provider); and
  • the most suitable type of service that can be provided to the patient safely.

For example, health services such as lab tests, surgeries, and visits to the doctor’s office, as well as certain supplies and equipment (such as wheelchairs and walkers) are typically considered medically necessary to treat certain diseases or conditions. Also, some preventive care may be considered medically necessary. Medicare will pay for these things.

On the other hand, there are some surgeries or procedures that aren’t considered a medical necessity under Medicare, such as cosmetic surgery. You’ll have to pay for this type of surgery or procedure yourself (if you decide to get it) since Medicare won’t pay the bill.

While “medically necessary” might seem like a subjective term, it can be boiled down to a pretty simple definition. Under Medicare, a service that is “medically necessary” is a service that Medicare pays for at this time for the particular diagnosis. The main terms to focus on are “at this time” and “diagnosis.” Any procedure could eventually become medically necessary, for a given diagnosis, at some time in the future.

As a practical matter, determining what exact medical services are considered medically necessary according to Medicare (and therefore are covered under the program) can sometimes be difficult for people. If you aren’t sure whether a particular type of service is covered or not under Medicare, be sure to check with your provider before you get the service.

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