Which payer will only cover care that it determines to be medically necessary?

Which payer will only cover care that it determines to be medically necessary?

• A. Medicaid
• B. Private insurance
• C. Medicare
• D. VA benefits

Answer: (C)

Medical necessity is the gatekeeper for what gets paid. Medicare pays for services and supplies only if a clinician documents that they are reasonable and necessary to diagnose or treat a patient’s medical condition, and they’re provided in an appropriate setting. Because of this standard, Medicare will cover care only when it determines that the care is medically necessary. While other payers also use medical necessity as a criterion, Medicare is the payer most consistently bound by this requirement across many benefits, making it the best fit for the idea that coverage is limited to medically necessary care.

Medical necessity is the gatekeeper for what gets paid. Medicare pays for services and supplies only if a clinician documents that they are reasonable and necessary to diagnose or treat a patient’s medical condition, and they’re provided in an appropriate setting. Because of this standard, Medicare will cover care only when it determines that the care is medically necessary. While other payers also use medical necessity as a criterion, Medicare is the payer most consistently bound by this requirement across many benefits, making it the best fit for the idea that coverage is limited to medically necessary care.