Medicare provides coverage for a wide range of medical services and procedures. However, understanding what Medicare covers can be complex. This article aims to clarify the basics of how Medicare determines coverage.

What Does Medicare Cover?

Medicare coverage focuses on what is considered “medically necessary.” A medically necessary service or procedure is one that is required to diagnose or treat an illness or injury, or to improve the functioning of a malformed body part.

How Does Medicare Determine Coverage?

Medicare coverage decisions are based on national and local policies. The process includes:

• Medical Necessity: Medicare only covers services and supplies that are considered medically necessary. Doctors and healthcare providers must provide documentation to support the need for the service or procedure.
• Medical Coding: Providers use specific codes to report medical services and procedures to Medicare. These codes must match the services billed to Medicare and be justified as medically necessary.
• Participating Providers: Medicare covers services provided by participating providers who accept Medicare assignment. This means they agree to the Medicare-approved amount for a service as full payment.

Medicare has a tool that you can use to check if your test, item, or service is covered. You can utilize this tool here.

Understanding what Medicare covers and the criteria used for determining coverage will help you make informed decisions. Always check with Medicare or your insurance provider to confirm the coverage of specific services and procedures.

If you have any questions about Medicare coverage or need assistance, we’re here to help! Our agents are collectively licensed in all 50 states to offer free Medicare guidance, so you don’t have to face Medicare alone. At AMAC, we make Medicare make sense. Call 855-611-4856 to speak to an agent today!