Covered v. Non-Covered Services

Non-Covered Services

View the following information below:

Medical Necessity

Medical necessity is defined as services that are reasonable and necessary for diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.

Medicare covers services it views as medically necessary to diagnose or treat health conditions. If those conditions produce debilitating symptoms or side effects it would also be considered medically necessary to treat those as well.

To be considered medically necessary, items and services must meet certain qualifications:

  • Consistent with symptoms or diagnosis of illness or injury under treatment

  • Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational)

  • Not furnished primarily for convenience of patient, attending physician or other physician or supplier

  • Furnished at most appropriate level that can be provided safely and effectively to patient

Services also need to meet criteria provided in the Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). These determinations are decided by CMS and Medicare contractors to determine if Medicare will pay for a specific item or service, or if additional rules apply to make payment. Not every procedure code has an NCD or LCD policy attached to it. If there is not a clear coverage policy available, providers should focus on "what constitutes medical necessity."

Non-Covered vs Statutorily Excluded

Non-Covered: An item or service may be non-covered if the coverage criteria are not met per the NCD or LCD; it would be considered not reasonable or necessary. For these services that do not meet policy criteria, a mandatory Advance Beneficiary Notice of Noncoverage (ABN) is required with the GA modifier appended upon claim submission.

Statutorily Excluded: These items are excluded by statute and not recognized as part of a covered Medicare benefit. A voluntary ABN may be given and the claim is submitted with the GY modifier, indicating the voluntary ABN.