What Is Medically Necessary?

Medically necessary services are treatments, procedures, or supplies needed to diagnose or treat a medical condition according to accepted medical standards. Health insurers, including Medicare, typically cover services that meet these standards because they're considered appropriate, reasonable, and required for effective patient care.

Why medical necessity matters

• Determines insurance coverage: Insurers generally cover treatments only if they're deemed medically necessary, directly affecting what services you can receive.
• Prevents unnecessary treatments: This standard helps prevent healthcare waste and excessive costs by limiting coverage to treatments considered effective and appropriate.
• Protects patient health: Ensuring care meets accepted standards helps maintain safe, effective, and appropriate medical practices.

How Solace can help

A Solace advocate can help clarify whether your treatments or procedures meet the medical necessity criteria required by your insurance provider. Advocates can also assist you in appealing denied claims, navigating prior authorization requirements, and communicating effectively with your healthcare providers about treatment options.

What to do next

Unsure if a procedure or treatment qualifies as medically necessary? A Solace advocate can help you understand your coverage and address any concerns about your care. Find an advocate today.