Food, water, shelter. These are essential to everyday life. Beyond that, not everyone agrees. What you think you need, what your doctor thinks you need, and what Medicare thinks you need may not always line up. It comes down to what Medicare considers to be medically necessary.

What Is Medical Necessity?

Medicare only covers care it considers to be medically necessary. The Centers for Medicare & Medicaid Services defines it as:

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.

Unfortunately, it does not provide a list of “accepted standards of medicine”. That gets complicated when your doctor recommends a test or medicine but Medicare says no. When that happens, you may have to appeal your case to Medicare. Your doctor may need to fill out paper work on your behalf to get a service covered. Even then, there is no guarantee Medicare will agree.

YES – Local and National Coverage Determinations

Medicare provides a list of covered services on a national level, known as national coverage determinations (NCDs). Be sure to check out their database. That does not mean that these services will be covered for every person. You may need to have certain medical conditions, risk factors, or other criteria to qualify for coverage. Simply put, Medicare puts restrictions on these services because they want to know if the test is medically necessary FOR YOU.

Other covered services may be assigned a local coverage determination (LCD). In those cases, whether or not a service gets covered depends where you live. A private insurance company that processes Medicare claims in your area, known as a Medicare Administrative Contractor (MAC), makes that decision.

YES – FDA Approved Medications and Medical Devices

Medicare covers FDA-approved medications. To be clear, it only covers those drugs when prescribed for FDA approved reasons. This gets tricky because many medications have “off label” uses.

Take gabapentin as an example. The FDA approved the medication for treatment of partial seizures, post-herpetic neuralgia, and restless leg syndrome. However, many healthcare providers also use it to treat alcohol dependence, attention deficit disorder, bipolar disorder, complex regional pain syndrome, diabetic neuropathy, fibromyalgia, neuropathic pain, trigeminal neuralgia, and migraines. Medicare does not cover it for those indications.

*Because gabapentin is available as a generic medication, pharmaceutical companies do not see a way to profit from it. That makes it unlikely they will pursue clinical trials to show the drug works for these other indications. That’s unfortunate because it precludes coverage for so many people who could benefit from it.

YES/NO – Clinical Trials

Some people turn to clinical trials when conventional medicine is not helping them. Cancer treatment is a prime example. Medicare will cover some of your care under a clinical trial but only in the following situations:

• The clinical trial intends to treat a disease and meets all ethical, safety, and scientific guidelines set by the federal government.
• The person signing up for the clinical trial has the condition and is not a healthy volunteer.

As a general rule, Medicare does not cover experimental treatments. That means the cost of the item or service being investigated usually falls to the researchers and/or organizations conducting the study. Medicare will cover care for a study participant needed to monitor treatment effects and prevent complications. It covers other routine care as well. However, it will only cover those services if they fall under an LCD or NCD.

*The FDA approved the drug aducanumab (Aduhelm) as a treatment for Alzheimer’s disease in 2021. CMS gave it a national coverage determination in 2022 but only for people who are in an approved clinical trial. This is one of the rare times that Medicare will pay for the investigational treatment in a clinical trial.

YES/NO – Dental, Hearing, and Vision Care

Original Medicare limits coverage for dental, hearing, and vision coverage care to what it considers absolutely essential. This doesn’t mean you won’t get any care at all but it means you likely won’t get the routine care you need.

Dental: Medicare covers dental evaluations before high risk surgeries like heart valve replacement or a kidney transplant. It also pays for dental procedures needed to reconstruct the jaw or to repair a fracture of the jaw.

Hearing: Medicare may pay for a hearing test if you have symptoms that need evaluation but it won’t pay for hearing aids. It will, however, pay for cochlear implants if you failed to respond to hearing aids.

Vision: Medicare covers screening and treatments for age-related macular degeneration, cataracts, diabetic retinopathy, and glaucoma. The only time Medicare pays for corrective lenses is after cataract surgery.

*Medicare Advantage plans may offer supplemental benefits that include dental, hearing, and/or vision coverage.

YES/NO – Hospital Stays

Staying overnight in a hospital does not mean that Medicare sees your stay as medically necessary. In 2013, CMS passed what became known as the 2-midnight rule. The rule defined what it meant to be an “inpatient”. An inpatient hospital stay will be covered by Part A only when you are expected to stay in the hospital for two or more midnights and it was medically necessary to receive care in the hospital, i.e., your care could not be safely managed from home, a skilling nursing facility, a doctor’s office/clinic, or another kind of medical facility.

When you do not satisfy these criteria, you are placed “under observation”. Part A won’t cover you in that case. Instead, you would turn to Part B. Unfortunately, that usually leads you to pay more in out-of-pocket costs -even if you got the same exact care you would have gotten as an “inpatient”.

*The 2-midnight rule does not mean that you have to stay in the hospital for two-midnights. It means that you were sick enough when you got to the hospital that it was reasonable to expect that you would need medically necessary care in the hospital that long.

NO – Cosmetic Surgery and Medications

Looking better is not something Medicare considers medically necessary. Cosmetic surgeries are not covered unless there is a medical indication to perform them. For example, someone could not get a rhinoplasty, aka a “nose job”, for cosmetic reasons but they might be able to get one if they had a nasal obstruction that affected their breathing.

Part D doesn’t cover medications used for cosmetic reasons, whether for treatment of hair loss or weight management. This rule holds even for someone who has health complications caused by morbid obesity.

NO – Custodial Care

As you get older, you may need help managing your activities of daily living (ADLs). ADLs include things like bathing and other grooming activities, eating and preparing food, dressing, housekeeping, managing your finances, taking your medications, toileting, and transferring yourself in and out of a chair, a bed, or even a bathtub. Someone does not necessarily need medical training to help you do them. You might find help with family members or loved ones but you could also hire a home health aide or nursing assistant.

CMS defines these tasks as custodial care, not medical care, even though they clearly have an impact on your health and your life. Original Medicare will only cover skilled care provided by a medically trained professional if their services are considered medically necessary and they are ordered by a physician. This can include physical therapy, occupational therapy, speech therapy, and skilled nursing care.

*Some Medicare Advantage plans may offer supplemental benefits that offer adult day care and home services for custodial needs.

 

CMS Finalizes Medicare Coverage Policy for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease | CMS. (2022). CMS.gov. https://www.cms.gov/newsroom/press-releases/cms-finalizes-medicare-coverage-policy-monoclonal-antibodies-directed-against-amyloid-treatment

CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1753FC) | CMS. (2021). CMS.gov. https://www.cms.gov/newsroom/fact-sheets/cy-2022-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-0

Fukada, C., Kohler, J. C., Boon, H., Austin, Z., & Krahn, M. (2012). Prescribing Gabapentin off Label: Perspectives from Psychiatry, Pain and Neurology Specialists. Canadian Pharmacists Journal / Revue Des Pharmaciens Du Canada, 145(6), 280-284.e1. https://doi.org/10.3821/145.6.cpj280

ITEMS AND SERVICES NOT COVERED UNDER MEDICARE ICN 906765. (2018, August). https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/items-and-services-not-covered-under-medicare-booklet-icn906765.pdf

Local Coverage Determinations | CMS. (2022). CMS.gov. https://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs

Medicare Prescription Drug Benefit Manual Chapter 6 -Part D Drugs and Formulary Requirements. (2016). CMS.gov. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Part-D-Benefits-Manual-Chapter-6.pdf

NCD – Routine Costs in Clinical Trials (310.1). (2016). CMS.gov. https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=1&fromdb=true