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How does Medicare define what is 'medically necessary'?

September 01, 2002

According to the Medicare Program Integrity Manual, a service is considered reasonable and necessary if it is:

  • safe and effective
  • not experimental or investigational (exception Qualifying Clinical Trials services)
  • appropriate in duration and frequency
  • furnished in an appropriate setting
  • ordered and/or furnished by qualified personnel
  • one that meets but does not exceed the patient's medical needs, and
  • at least as beneficial as an existing and available medically appropriate alternative.
Submitted by YSM Web Group on July 23, 2012