How Does Medicare Decide If My Treatment is Medically Necessary

How Does Medicare Decide If My Treatment is Medically Necessary? 

There are stipulations regarding Medicare’s coverage of specific medical services and supplies. Most benefits apply if your care is deemed medically necessary by a Medicare-approved physician. This designation is a requirement for inpatient and outpatient procedures, therapies like counseling and physical rehabilitation, as well as prescription medications. Because this designation is key to receiving Medicare benefits, you may be wondering how Medicare determines whether something is a medical necessity.

How does Medicare decide if my treatment is medically necessary?

The strict definition as provided by Medicare for determining medical necessity is “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.” What this definition essentially does is require that covered care is provided only for healthcare reasons that are accepted within the medical community in general. And that treatment must be to treat or cure an illness or injury.

As a result, lifestyle care, including things like cosmetic surgery, is deemed ineligible. Medicare also refuses to cover many erectile dysfunction or other sexual health aids and treatments because they are not considered a medical necessity according to Medicare’s definition.

There may be some situations where a medication is used for “off-label” treatment, meaning the medication is meant to be used primarily to treat one condition, but it also treats other conditions that it was not designed to treat. Medicare may cover some off-label usage of prescription medications when a Local Coverage Determination (LCD) has not been made or when the medication’s off-label usage is not documented as unsupported. For more information on your coverage for off-label usage of medications, contact your plan provider.

Work closely with your doctor

What’s important to remember is that some situations where coverage is in question may require your doctor to step in. In these cases, Medicare may require some type of documentation from your doctor stating the medical necessity of a particular treatment. Your doctor will not be able to change Medicare’s definition of a medical necessity, but he or she may be able to explain your case in enough detail that it can clearly be demonstrated that a treatment is medically necessary to address a medical concern.

If you’re denied coverage

In some cases coverage will be denied due to a medical service not meeting Medicare’s definition. In these cases, you do have the option to file for an exception waiver. You may need to do this if a particular medication you’ve been prescribed is not covered by your plan’s formulary, but no suitable alternative exists. Once again, your doctor will likely need to be involved in this process to explain the purpose of the medication in light of your medical condition and history while also demonstrating that no suitable alternative can be substituted.