Medically Necessary Services - What Is And Isn’t Covered

By: Meredith Miller
Published: Wednesday, October 24 2018
Last Updated: 4 years ago

For all health insurance purposes, there are procedures that are deemed necessary and procedures that are deemed unnecessary, and Medicare is no different. The way Medicare handles medically necessary procedures and services closely follow that of traditional health insurance plans. So, the question remains, what exactly are medically necessary services covered under Medicare?

What Does Medically Necessary Mean?

The term medically necessary means that any procedure or medical device that is deemed to prevent or treat an illness. So, if you have been diagnosed with an illness or injury, any equipment or services needed for treatment is considered medically necessary. There are other procedures that might prevent you from becoming ill, and some of these services may also be deemed medically necessary as far as Medicare is concerned.

Example of Medically Necessary Services

Let’s take a look at a real-world example for someone diagnosed with sleep apnea. There is special equipment necessary to treat the sleeping disorder called a CPAP machine. Under Medicare, the CPAP machine would be considered a medical necessity, because it is required in order to treat sleep apnea.

Sticking with the sleep apnea example, if your doctor sees you are having symptoms of sleep apnea he or she is allowed to order the sleep study test for proper diagnosis. This test would also be considered a medical necessity for similar reasons as the CPAP, it’s required in order to get the proper treatment.

Does Medicare Cover Services Deemed a Medical Necessity?

Medicare covers all expenses considered being medically necessary. So, if your doctor deems it necessary for you to have a test then Medicare will cover it. This is providing the test or equipment to treat the illness is within the means of regular medical treatment. That means that if the treatment or test is not considered a standard procedure then Medicare will not cover it.

What Medically Necessary Services Are Covered?

Of course, everyone has heard of Medicare medically necessary procedures. These procedures are procedures that are covered by Medicare because they were deemed necessary procedures either by your doctor or Medicare. The doctor is the one who needs to consider it a necessary procedure and prove to Medicare the procedure was necessary. Here are a few examples of what is considered a necessary procedure under Medicare.

  • Durable Medical Equipment
  • Home Health Care
  • Ambulance Services
  • Mental Health Services
  • Clinical Research

This is just a partial list of what Medicare Part B will consider necessary and therefore covered. The mental health coverage is for inpatient, outpatient, or partial hospitalization. The Medicare Part B will cover almost anything your doctor will consider necessary to diagnose and treat you.

Services Not Covered

Indeed there are some services not medically necessary and therefore not covered by Medicare. These services are basic services that might be covered by ordinary health insurance, but for Medicare, they are considered not medically necessary. Here is a list of some of the service considered not medically necessary and may not be covered by your plan.

  • Routine Dental Services
  • Routine Vision Services
  • Most Hearing Services
  • Acupuncture
  • Vitamins
  • Over-the-Counter Medications

This is not a complete list of the services not considered necessary by Medicare. There are of course many other services that are not considered to be necessary. The dental procedures not covered by Medicare are:

  • Fillings
  • Exams
  • Cleaning
  • Extraction

The vision procedures not covered by Medicare are:

  • Eye Exam
  • Eyeglasses
  • Contacts

Why Medical Necessity Documentation Is Important

It is important to have documentation when trying to prove the necessity for the coding. If you have the documentation necessary to prove that the procedure or equipment is necessary then Medicare is more likely to cover the expense. Without the medical documentation to prove it is a necessity Medicare might not cover the necessary test, procedure, or equipment you need.

Is There a Way to Get Vision and Dental Coverage With Medicare?

Yes, there are some Medicare Advantage plans that will cover these services. If you wear glasses and you think you will need to go to the dentist you might want to consider getting a Medicare Advantage plan over a Medicare Supplement plan.