How Does Medicare Decide if a Service is Covered?

September 20, 2009 by admin

Benefits available to Medicare beneficiaries are called "covered" services. First, your doctor must decide that a particular service or procedure is necessary to treat your condition. Items and services covered by Medicare are broadly defined in the Social Security Act (a law). Certain items are specifically excluded from coverage, while others are subject to interpretation. So, in some cases, even if your doctor prescribes an item or service, Medicare may not pay for it. Medicare coverage decisions are either "national" (applicable to everyone) or "local" (established by the company that processes Medicare claims for a distinct region). Additional information about Medicare coverage can be found in the Your Medicare Coverage section of Medicare's web site. Requests for Medicare coverage are evaluated according to proscribed procedures. The first action is a determination that the law allows it to be covered. After that we look carefully at the scientific evidence to support coverage of the item or service for all Medicare beneficiaries when their doctor decides the service is needed.