Medicare often states that services, equipment, and treatment must be medically necessary for them to be covered. If something is deemed not to be medically necessary, Medicare may not cover it.

Medicare offers coverage for inpatient care in hospitals and skilled nursing facilities. It also covers outpatient care, durable medical equipment, some in-home healthcare, and hospice care.

Medicare Advantage (Part C) plans may also offer additional benefits, such as vision, hearing, and dental.

Medicare defines medically necessary services as supplies or services that are reasonable and necessary to diagnose or treat an illness or injury. They must also meet the accepted standards of medical practice.

Medicare coverage is limited to services, supplies, and treatments that are deemed medically necessary. If a service is not considered medically necessary, Medicare will generally not cover it.

The Centers for Medicare & Medicaid Services (CMS) helps determine what services and supplies are deemed medically necessary and are, therefore, covered by Medicare. CMS has its own research that aids in the national coverage determinations (NCDs).

The NCDs are made through an evidence-based process that also allows for public participation. The research from CMS is supplemented by outside assessments and consultations with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC).

The MEDCAC was developed to provide independent guidance and expert advice to the CMS on certain clinical topics.

»Learn more: What Medicare covers

There are certain supplies and services that the CMS deems medically unreasonable or unnecessary. Therefore, these services and supplies are not covered by Medicare:

  • services provided in a hospital setting that could have been provided in a lower cost setting, such as at home or in a nursing home
  • hospital services that are given in a timeframe that exceeds the Medicare length of stay limits
  • excessive diagnostic or therapy procedures
  • management and evaluation services that exceed those considered medically necessary
  • unrelated tests, screenings, exams, or therapies where an individual has no symptoms or diagnoses
  • unnecessary services, like transcendental meditation, based on a person’s diagnosis
  • items and services that are administered to cause or assist in death (assisted suicide)