Senior man doing research on computer of what is considered medical necessity in medicare.

Medical Necessity Services in Medicare?

If you are enrolled in Medicare, you may have come across the term “medically necessary.” This term is used to describe whether Medicare will cover a service or treatment. According to Medicare, a treatment is medically necessary if it is needed to diagnose or treat an illness, condition, or disease. It must also be provided for the diagnosis, direct care, or treatment of a medical condition. 

The service or treatment must also meet the standards of good medical practice. This means treatments such as alternative medicine or certain cosmetic procedures will not be covered by Medicare since they are not deemed medically necessary. Medically necessary treatments include preventive screenings, diagnostic tests, flu shots, and other services.

Medically Necessary Services in Medicare

Original Medicare is made up of Medicare Part A and Part B. Part A provides hospital insurance while Part B provides medical insurance. Under Part A, you will receive coverage for medically necessary inpatient services, such as skilled nursing facility care, hospice care, hospital care, and some home health services.

Part B covers outpatient services such as preventive screenings, colonoscopies, diabetes screening tests, mammograms, wellness exams, lab tests, durable medical equipment, vaccinations and shots, and other approved medically necessary services. If you receive any service that is not deemed medically necessary, you will be faced with the full cost of the service.

Medicare Advantage (Part C) plans are required to cover at least the same services as Original Medicare. In addition, some Part C plans also cover prescription drug coverage, routine dental, vision, or hearing services.

Seniors at resort having dinner discussing what medical necessities are in medicare.
Medicare does not cover routine dental services such as fillings, dental exams, and extractions.

What Does Medicare Not Cover?

Medicare does not cover routine dental services such as fillings, dental exams, and extractions. Non-covered services also include routine vision services, hearing coverage, acupuncture, vitamins, and over-the-counter medications. 

Non-medically necessary services also include services received when you have exceeded the Medicare-approved stay length, fertility treatment drugs, or weight loss drugs. However, Medicare may cover a service that is normally exempted if it is required for a covered procedure that is necessary to better your overall health.

Are you interested in learning more about the Medically necessary services covered by Medicare? Give Turning 65 Solutions a call today!

Sources: 

https://www.medicare.org/articles/what-does-medically-necessary-mean/

https://www.ehealthinsurance.com/medicare/resources/medically-necessary-definition

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