Services must be deemed medically necessary for Medicare to cover them. You can appeal if a service you need is denied.
Updated May 19, 2023 · 1 min read Written by Alex Rosenberg Lead Writer Alex Rosenberg
Lead Writer | Medicare, health care, legislation
Alex Rosenberg is a NerdWallet writer focusing on Medicare and information technology. He has more than 10 years of experience researching and writing about health care, insurance, technology, data privacy and public policy. His research has supported lawmakers in the Wisconsin State Legislature as well as health systems and national health authorities in the U.S. and more than 10 other countries. He is based in Eau Claire, Wisconsin.
Assigning Editor Holly Carey
Assigning Editor | Medicare
Holly Carey joined NerdWallet in 2021 as an editor on the team responsible for expanding content to additional topics within personal finance. She currently leads the Medicare team. Previously, Holly wrote and edited content and developed digital media strategies as a public affairs officer for the U.S. Navy. She is based in Virginia Beach, Virginia.
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Medicare covers a lot of services, but only when they’re medically necessary.
Medically necessary services are “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,” according to the Centers for Medicare & Medicaid Services, or CMS [0]
Centers for Medicare & Medicaid Services . Glossary: Medically Necessary. Accessed May 17, 2023.You can look services up online or talk to your health care providers to find out whether and how Medicare covers them. If Medicare won’t cover a service that you or your doctor thinks is necessary, you can appeal that decision.
You can check how Medicare covers items and services online at medicare.gov/coverage .
If your health care provider thinks that a service you request won’t be covered by Medicare, they might give you notice with a Medicare Advance Beneficiary Notice of Non-Coverage , or ABN [0]
Centers for Medicare & Medicaid Services . Your Protections. Accessed May 17, 2023.ABNs are provided only to people with Original Medicare ( Part A and/or Part B ). If you have Medicare Advantage , you might get a different notice or form.
Medicare Advantage is an alternative to traditional Medicare offered by private health insurers. It covers the same benefits as Medicare Part A and Part B.
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Average Medicare star rating, weighted by enrollment. Star ratings are determined by the Centers for Medicare & Medicaid Services (CMS).
Get a quote on NerdWalletWe will connect you with Medicare companies based on the information you provide. They will help you find a plan that suits your needs. If you prefer to speak to a licensed insurance agent right away, please call the number listed.
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CMS Star Rating
Average Medicare star rating, weighted by enrollment. Star ratings are determined by the Centers for Medicare & Medicaid Services (CMS).
Get a quote on NerdWalletWe will connect you with Medicare companies based on the information you provide. They will help you find a plan that suits your needs. If you prefer to speak to a licensed insurance agent right away, please call the number listed.
States available 49 states, Washington, D.C., and Puerto Rico Members in high-rated plans High (90% or more) Member satisfaction Above average (855) 432-0512 M-F 9am-9pm ET, Sa 10am-9pm ET Speak to a licensed insurance agent on askchapter.org See more plansMedicare’s decisions about medical necessity happen at three levels, from most general to most specific [0]
Centers for Medicare & Medicaid Services . Learning What Medicare Covers & Your Costs. Accessed May 17, 2023.
Laws. Federal and state laws can set requirements for what’s covered.National coverage determinations, or NCDs. Using a public, evidence-based process, Medicare decides whether and how a certain item or service is covered for the whole country.
Local coverage determinations, or LCDs. If a particular item or service isn’t included in relevant laws or NCDs, Medicare contracts with local companies that make coverage decisions. LCDs don’t apply nationally — they’re geographically limited to certain areas according to Medicare’s contracts.
Medicare doesn’t pay for “medically unreasonable and unnecessary services and supplies to diagnose and treat a Medicare patient’s condition,” according to CMS [0]
Centers for Medicare & Medicaid Services . Items & Services Not Covered Under Medicare. Accessed May 17, 2023.
Here are a few examples of what CMS considers medically unreasonable and unnecessary:
Tests or therapies that aren’t related to a patient’s symptoms or conditions.Getting more or longer services than necessary, such as staying in the hospital or continuing therapy too long.
Services provided at a hospital when they could have been provided in lower-cost settings.If a service or item is denied because it’s not medically necessary, you can appeal that decision.
You’ll receive a written notice that explains what was denied, the reasons for denial and how you can appeal. You then need to submit the necessary information before any appeal deadlines [0]
Centers for Medicare & Medicaid Services . How Do I File An Appeal?. Accessed May 17, 2023.If your appeal is denied, it’s not necessarily the end of the road. You can escalate the appeal to a higher level. As with the original denial, the written notice you receive about a decision on your appeal will include instructions for your next steps.
If you have additional questions about Medicare, visit Medicare.gov or call 800-MEDICARE (800-633-4227, TTY 877-486-2048).
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Alex is a NerdWallet writer focusing on Medicare and information technology. He has written about health, tech, and public policy for over 10 years. See full bio.
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