{"id":355826,"date":"2018-08-09T16:03:50","date_gmt":"2018-08-09T21:03:50","guid":{"rendered":"https:\/\/ability-fl-prod.internetbrands.com\/ability-law\/healthcare\/patient-rights\/medical-necessity-and-the-law.html"},"modified":"2026-08-17T17:42:00","modified_gmt":"2026-08-17T22:42:00","slug":"medical-necessity-and-the-law","status":"publish","type":"page","link":"https:\/\/www.findlaw.com\/healthcare\/patient-rights\/medical-necessity-and-the-law.html","title":{"rendered":"What Does the Term “Medical Necessity” Mean?"},"content":{"rendered":"\n
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What Does the Term "Medical Necessity" Mean?<\/h1>\n\n
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\n By Melissa McCall, J.D.<\/a> | Legally reviewed by Aviana Cooper, Esq.<\/a>\n | Last updated\n
\n \n <\/i>\n Legally Reviewed\n <\/summary>\n\n
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This article has been written and reviewed for legal accuracy, clarity, and style by FindLaw\u2019s team of legal writers and attorneys<\/a> and in accordance with our editorial standards<\/a>.<\/em><\/p>\n\n <\/div>\n <\/details>\n\n

\n \n <\/i>\n Fact-Checked\n <\/summary>\n\n
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The last updated date refers to the last time this article was reviewed by FindLaw or one of our contributing authors<\/a>. We make every effort to keep our articles updated. For information regarding a specific legal issue affecting you, please contact an attorney in your area<\/a>.<\/em><\/p>\n\n <\/div>\n <\/details>\n<\/section>\n\n\n

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Key Takeaways<\/h2>\n
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Medical necessity is the standard insurers use to decide whether a treatment is covered, but each program\u2014Medicare, Medicaid, and private plans\u2014defines it differently. Medicare relies on whether a service is \u201creasonable and necessary,\u201d while Medicaid\u2019s state\u2011specific rules often mirror Medicare and private insurers follow contract terms.<\/p>\n<\/div>\n<\/div>\n<\/div>\n\n <\/div>\n <\/div>\n<\/div>\n\n\n

Health insurance companies use “medical necessity” or “medically necessary” to decide what medical treatments they will cover. These companies include public health insurance programs like Medicare and Medicaid, as well as private insurance companies. Medically necessary services are services or supplies that meet accepted medical standards and are needed to diagnose or treat medical conditions.<\/p>\n

Depending on the plan’s terms, many plans won’t cover medical care that isn’t approved as “medically necessary<\/a>.” But the term’s definition is often a source of confusion and ambiguity.<\/p>\n

This FindLaw article outlines different definitions of medical necessity and how to appeal a denied claim.<\/p>\n

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If your claim is denied, you can pursue an internal or external appeal to challenge the decision. You don’t have to face this alone\u2014a healthcare attorney near you<\/a> can help navigate the process. Find local legal help.<\/p>\n

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Definitions of Medical Necessity<\/h2>\n

Different health insurance programs and companies have their own definitions of medical necessity.<\/p>\n

Medicare<\/h3>\n

Medicare is a federally administered health insurance program for older adults and those with kidney disease. For the Medicare program, the\u00a0Social Security Act<\/a>\u00a0defines “medically necessary” for Medicare coverage.<\/p>\n

Medicare will not pay expenses that are not “reasonable and necessary<\/a>” for the following:<\/p>\n