How Does Medicare Define “Medically Necessary”? 

Original Medicare provides healthcare coverage to seniors over 65 in the United States, and many individuals under 65 with qualifying disabilities. While the program covers a multitude of healthcare services and equipment, Medicare benefits do have limits. Some coverage limitations are based on the types of services and supplies you require and whether Medicare considers them medically necessary.

What does “medically necessary” mean?

When it comes to obtaining a coverage determination for a medical service or product, Medicare requires that the item be of medical necessity. In fact, Medicare benefits will cover services and supplies ordered by your physician are necessary for diagnosis or treatment of an illness or injury. In most cases, simply having your doctor order a procedure, treatment or medication will be enough to satisfy Medicare’s definition of medically necessary. In other cases, you may need to have your doctor help you file for an exception waiver in order to obtain coverage for a medical service or product that isn’t explicitly listed as a covered item in your Medicare benefits plan.

Medically necessary usually means anything that is required to protect health and prevent disease or injury. Medicare’s own official definition of medically necessary reads as “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

Based on Medicare’s definition, meeting the criteria for accepted standards of medicine usually falls under doctor-ordered treatment. Once these criteria are satisfied, you would then need to look at the details of your Medicare benefits and plan criteria to determine whether something is covered, and if so, to what extent.

What is excluded from Medicare coverage?

There are some items that Medicare coverage excludes from being labeled as medically necessary. These items usually pertain to lifestyle concerns, but things are not always black and white when it comes to defining medical necessity.

For example, cosmetic surgery is not covered by Original Medicare insurance. Medicare views cosmetic, or plastic, surgery as an elective procedure. It does not provide coverage under any part of Medicare for cosmetic surgery. You may be able to obtain coverage for a procedure that produces aesthetic-enhancing results as long if the reason for the procedure is one that is of medical necessity. 

As an example, Medicare will cover eyelid surgery, also known as a blepharoplasty, as long as the reason for the surgery is to improve your vision and reduce the chances of injuries due to vision problems. Blepharoplasty may also subjectively improve your appearance, making you look younger and healthier.

Even though Medicare recipients may gain a cosmetic benefit from having a blepharoplasty performed, Medicare benefits will still cover the procedure since it is not being performed for cosmetic purposes. In this case, as long as a Medicare-participating physician has ordered the surgery to improve your health, Medicare will cover the procedure since it is considered medically necessary. The cosmetic benefit is a side effect of the surgery and is not the main function of the procedure.

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