Medical Necessity

NOTIFICATION TO PHYSICIANS AND OTHER PERSONS LEGALLY AUTHORIZED TO ORDER TESTS FOR WHICH MEDICARE REIMBURSEMENT WILL BE SOUGHT

Medical Necessity

Under section 1862(a)(1) of the Medicare law, claims submitted for service or supplies will only be paid if the service meets Medicare coverage criteria, and is "reasonable and necessary" for the beneficiary (patient), given his/her medical condition.  If Medicare determines that a particular service, although it would otherwise be covered, is "not reasonable and necessary" under Medicare program standards, Medicare will deny payment for that service.

MEDICARE will pay only for service or supplies that:

• are proper and needed for the diagnosis or treatment of the patient's medical condition according to coverage criteria.
• are used for the diagnosis, direct care, and treatment of the patient's medical condition according to coverage criteria.
• meet "frequency limitations."
• are not for experimental or research use.
• are not mainly for the convenience of the patient and his/her doctor.

Physicians are required by Federal law to provide a diagnosis that medically justifies the laboratory test(s) at the time of the request.  Prior to furnishing the service, the physician/provider must present to the patient an Advanced Beneficiary Notice (ABN) that Medicare will probably deny payment and that the patient will be personally and fully responsible for payment if Medicare denies payment.

All diagnosis information should be designated in the spaces provided on the Outreach requisition for each requested laboratory test.  

National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) are readily available upon request or from CMS website(s).