One of Medicare’s main rules is that a service or supply must be “medically necessary” for Medicare to cover it.
A service or supply that is required to either diagnose or treat a medical issue is considered medically necessary. Additionally, the service and/or supply must meet the standards of care.
- Lifesaving surgery
- Certain medications to treat an illness
- Durable medical equipment (i.e. oxygen pump)
- Preventative care
Medically Necessary Preventive Care
Preventative care is just what it sounds like: care that prevents disease. Preventive care ranges anywhere from examinations to immunizations. Medicare covers preventive care services 100%, when its requirements and restrictions are met.
Medicare has a helpful booklet describing the preventive care services that they cover. This booklet will describe:
- When services are covered
- Who they cover
- The costs of the service, if any
Below, you will find Medicare’s preventive care services:
- Abdominal aortic aneurysm screening
- Alcohol misuse screening and counseling
- Bone mass measurements
- Breast cancer screening (mammograms)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular disease screening
- Cervical and vaginal cancer screening
- Colorectal cancer screening
- Depression screening
- Diabetes screening and self-management training
- Glaucoma tests
- Hepatitis C screening test
- HIV screening
- Lung cancer screening
- Medical nutrition therapy
- Obesity screening and counseling
- Prostate cancer screening
- Sexually transmitted infections screening and counseling
- Shots (flu, pneumococcal, and Hepatitis B)
- Tobacco use cessation counseling
- “Welcome to Medicare” preventive visit
- Yearly “Wellness” visit
Restrictions and Limitations
In contrast, we will look at what Medicare doesn’t cover.
Even though a service is medically necessary, doesn’t mean that it will be covered every time. For example, we listed some limitations set by Medicare:
- A service that could have been in a less expensive setting
- Inpatient stay limit has been reached
- Usage limit exceeded
- Unnecessary screenings (no symptoms prevalent)
- Assisted suicide
Original Medicare has its limits on what it covers and what it doesn’t. It is good to note, Medicare is always changing. For instance, until 2010, Original Medicare didn’t cover preventive care services.
As of 2018, Medicare does not cover these items
- Long-term care (custodial care)
- Routine foot care
- Cosmetic surgery
However, there are a few circumstances where some of these items may be covered by Medicare. In order for Medicare to consider covering a service that it typically doesn’t, you and your doctor would need to file an appeal.
To file an appeal, you and your doctor must work together to provide the necessary documents to Medicare. You’ll need your Explanation of Benefit statement. This is the document that lists the codes used for the service as well as the dates the service was provided.
You’ll need to ask your doctor to provide you with any medical notes that might help prove that the service was medically necessary. Alternatively, have your doctor write a letter to explain why the service was needed.
Furthermore, you’ll need to complete the actual Medicare appeal form. You’ll want to submit this with your other documents. Finally, a Medicare representative will review your letters and will then decide.