{"id":355826,"date":"2018-08-09T16:03:50","date_gmt":"2018-08-09T21:03:50","guid":{"rendered":"https:\/\/content.findlaw-admin.com\/ability-law\/healthcare\/patient-rights\/medical-necessity-and-the-law.html"},"modified":"2025-01-23T17:42:18","modified_gmt":"2025-01-23T22:42:18","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":"Medical Necessity and the Law"},"content":{"rendered":"\n
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Medical Necessity and the Law<\/h1>\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

Health insurance companies use "medical necessity<\/a>" or "medically necessary" to decide what medical treatments they will cover. These companies include public health insurance like Medicare and Medicaid, and 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>\r\n

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

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

Definitions of Medical Necessity<\/h2>\r\n

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

Medicare<\/h3>\r\n

Medicare is a federally administered health insurance program for older adults and those with kidney disease. For the Medicare program, the Social Security Act<\/a> defines "medically necessary" for Medicare coverage.<\/p>\r\n

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