What Does Medically Necessary Mean with Medicare?

Medically necessary refers to items or services deemed necessary for diagnosing or treating a medical condition.

These items or services must be supported by medical evidence and provided by a medical professional to be considered medically necessary.

In the context of Original Medicare, medically necessary items or services are deemed essential to diagnose or treat a medical condition and are covered by Medicare. Medically crucial items or services may include doctor visits, hospital stays, surgeries, lab tests, prescription drugs, and medical equipment such as mobility aids and oxygen.

Medically Necessary Services Snder Original Medicare

Original Medicare covers various medically necessary services for diagnosing and treating medical conditions.

The list includes but is not limited to:

  • Inpatient hospital care
  • Skilled nursing facility care
  • Home health care
  • Hospice care
  • Doctor visits and consultations
  • Outpatient surgery

How Does Medicare Coverage Work with Medically Necessary Items?

Medicare Part A and Part B cover medically necessary items or services. Part A covers hospital stays, while Part B covers doctor visits, outpatient care, and medical equipment.

It is important to note that while Medicare covers medically necessary items or services, it does not cover everything. For example, Medicare does not cover cosmetic procedures or routine dental and vision care.

Understanding Coverage Limits

Medicare coverage for medically necessary items or services is subject to certain coverage limits. For example, Part B may only cover a certain number of yearly physical therapy appointments. Additionally, Medicare coverage may be subject to deductibles, copayments, and coinsurance.

It is important to understand your Medicare coverage limits to avoid unexpected costs. If you are unsure about your coverage for a specific item or service, you can consult your healthcare provider or contact Medicare directly.

What If I Need Items or Services Not Covered By Medicare?

If you need items or services that Medicare does not cover, other options may be available to help cover the costs. For example, specific health insurance plans may cover some items or services not covered by Medicare. Additionally, some organizations provide grants and assistance programs to help pay for medical bills. Researching and exploring all available options is essential to ensure you get the necessary items or services.

Bottom Line

Understanding what medically necessary means with Medicare is important to ensure you have access to the healthcare services and equipment you need. By knowing what is covered and what is not covered, you can make informed healthcare decisions and avoid unexpected costs. If you have questions about your Medicare coverage or what items or services are medically necessary, contact your healthcare provider or Medicare directly.

Sources: National Association of Insurance CommissionersMedicare.govNational Institute of Health


  • What is the definition of medically reasonable and necessary?

    Medically reasonable and necessary refers to the standard of care as defined by medical professionals in order to determine whether a treatment is appropriate for an individual. This standard includes factors such as the patient’s health history, current symptoms, diagnosis, and prognosis. Medical professionals will look at all of these factors in order to decide what type of care would offer the greatest benefit to the patient while still being cost-effective and within accepted medical standards. The determination of medically reasonable and necessary care can vary depending on an individual’s unique circumstances; it is important to consult with a healthcare professional in order to best understand how this standard applies to your specific situation.

Mark Prip

Since 2003, Mark Prip has been leading  Policy Guide, Inc., providing knowledgeable information about Medicare, life insurance, and dental coverage to clients in over forty states. With his unparalleled hands-on experience aiding countless Medicare beneficiaries in selecting an appropriate health plan, he is a prime example amongst other competitors for expertise and assistance. Mark has held his Florida Health & Life Insurance License (E051889) since 2003. View his license profile on the Florida Department of Insurance website.