Medically Necessary: Medicare Health Coverage Requirements

• by Christian Worstell
• July 24, 2023
• Reviewed by John Krahnert

In order for a health care service to be covered by Medicare Part A or Part B, it must be deemed medically necessary.

“Medically necessary” is defined as health care services or supplies that are necessary to prevent, diagnose, or treat an illness, injury, condition, disease, or their symptoms within accepted standards of medicine.

In other words, medically necessary services consist of health care that is necessary to keep you healthy.

What procedures and services are not medically necessary?

Procedures, services, supplies, equipment and medications that are designed to treat the following are generally not considered medically necessary and therefore are not covered by Original Medicare:

• Services for cosmetic purposes
• Fertility, sexual or erectile dysfunction services or products
• Weight loss or weight gain services and medication

Additional services that are not considered to be medically necessary include:

• Instances in which a hospital stay exceeds the Medicare-approved length of time
• Physical therapy treatment that surpasses the Medicare usage limit
• Treatment administered in a hospital that could have been delivered in a lower-cost setting

What else is medically necessary?

Medicare also includes a number of preventive health measures.

Although the following services and products may not seem medically necessary, they are covered by Medicare (certain restrictions are required for some services):

• Your Welcome to Medicare visit and your Annual Wellness Visit
• Bone mass measurements
• Colonoscopy
• Breast examinations and mammograms
• Cardiovascular disease screenings
• Counseling to help prevent the use of tobacco or alcohol
• Diabetes screenings and self-management training
• Glaucoma screenings
• HIV screenings
• Behavioral therapy for cardiovascular disease or obesity
• Medical nutrition therapy
• Pap tests and pelvic examinations
• Prostate cancer screenings
• Depression screenings
• Screenings and behavioral counseling for sexually transmitted infections
• Vaccines including flu, hepatitis B and pneumococcal
• Ultrasound screenings for abdominal aortic aneurysm

For more information on Medicare plan coverage

For more information about what Medicare does and does not cover, consult the Centers for Medicare & Medicaid Services’ Items and Services That Are Not Covered Under the Medicare Program.

Medicare Advantage plans cover everything Original Medicare covers and may cover benefits that Original Medicare doesn’t.

To learn more about Medicare Advantage plans where you live and the services they may cover – whether they are medically necessary or not – call today to speak with a licensed insurance agent.

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

 

 

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