In this guide 6 sections
“Medically necessary” sounds like a medical judgment. It is a legal and administrative one, made by a reviewer comparing a record against a checklist. The doctor may be certain the walker is necessary. If the visit note does not say the patient has a mobility limitation that impairs daily activities in the home and cannot be resolved with a cane, the walker is, to Medicare, not medically necessary. Understanding this is the key to getting things covered.
Where the standard comes from
Section 1862(a)(1)(A) of the Social Security Act says Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” Everything else follows from those words. Congress wrote them in 1965 and has barely changed them since; the meaning has been filled in by regulation, coverage determinations and decades of case-by-case decisions.
How it is applied
- National Coverage Determinations (NCDs) are issued by CMS and apply nationwide. They cover specific services and technologies, saying when Medicare will and will not pay. There are several hundred.
- Local Coverage Determinations (LCDs) are issued by the Medicare Administrative Contractors that process claims in each region, for services not covered by an NCD. They are far more numerous and much more specific, listing covered diagnoses, required findings and documentation. Most durable medical equipment, therapy and many tests are governed by LCDs.
- Where no NCD or LCD exists, the contractor decides case by case against the statutory standard, usually applying accepted standards of medical practice.
- Medicare Advantage plans must cover everything Original Medicare covers and follow NCDs and LCDs, but can add their own prior authorization and internal criteria, which is why the same service can be approved under Original Medicare and denied by a plan.
Why the same service is approved for one person and denied for another
Because coverage is decided on the record, not the person. Two patients with identical needs can have different outcomes if one doctor’s note contains the required elements and the other’s does not. A power wheelchair LCD, for example, requires documentation that the patient cannot accomplish mobility-related activities of daily living in the home with a cane or walker, cannot safely use a manual wheelchair, has been evaluated face-to-face, and that the home can accommodate the chair. A note saying “patient needs power wheelchair for mobility” meets none of those. A note that addresses each one does.
What the documentation must usually show
- 1.The diagnosis, with a code that supports the service under the applicable policy.
- 2.The clinical findings that establish the need: examination results, test values, functional limitations described specifically.
- 3.That less costly or less intensive alternatives have been tried or are inappropriate, when the policy requires it.
- 4.That the service is expected to help: to treat, to improve function, or to maintain function and prevent decline (after Jimmo, maintenance counts).
- 5.A face-to-face encounter within the required window, for services that require one.
- 6.The order itself, with all required elements: for equipment, the item, quantity, duration and any specifications; for therapy, the plan of care signed by the physician.
- 7.Continuing need, for ongoing services: progress notes showing the service is still required.
Phrases that help and phrases that hurt
Documentation language and coverage
“Unable to ambulate more than 10 feet without assistive device due to…”
- Tends to defeat it
- “Would benefit from a walker”
“Requires head-of-bed elevation above 30 degrees due to congestive heart failure with orthopnea”
- Tends to defeat it
- “Hospital bed for comfort”
“Resting oxygen saturation 87% on room air, chronic stable state”
- Tends to defeat it
- “Patient reports shortness of breath”
“Cane and standard walker trialed; unable to safely use due to bilateral upper extremity weakness”
- Tends to defeat it
- “Prefers wheelchair”
“Skilled therapy required to maintain current function and prevent decline in transfers”
- Tends to defeat it
- “Plateaued; continue for maintenance”
“Home evaluated; doorways and turning radius accommodate device”
- Tends to defeat it
- No mention of the home
| Tends to support coverage | Tends to defeat it |
|---|---|
| “Unable to ambulate more than 10 feet without assistive device due to…” | “Would benefit from a walker” |
| “Requires head-of-bed elevation above 30 degrees due to congestive heart failure with orthopnea” | “Hospital bed for comfort” |
| “Resting oxygen saturation 87% on room air, chronic stable state” | “Patient reports shortness of breath” |
| “Cane and standard walker trialed; unable to safely use due to bilateral upper extremity weakness” | “Prefers wheelchair” |
| “Skilled therapy required to maintain current function and prevent decline in transfers” | “Plateaued; continue for maintenance” |
| “Home evaluated; doorways and turning radius accommodate device” | No mention of the home |
What families can do
- Before an equipment or service request, ask the doctor’s office whether there is an LCD for it and what it requires. Medicare’s Coverage Database is public; a navigator, SHIP counselor or the supplier can find the policy.
- Describe the functional problem specifically at the visit. “She cannot get from the bed to the bathroom without holding the wall” is documentation; “she is getting weaker” is not.
- Ask that the note reflect what was discussed. Doctors write fast; a request to include the specific limitation is reasonable.
- For denials, get the policy, compare it to the note, and ask the office to add what is missing. This is what a letter of medical necessity should do: walk through the policy’s elements and show how the patient meets each one.
- Do not accept “Medicare doesn’t cover that” from a front desk without checking. It is often wrong, and the policy is the answer.
Questions families ask
What is the definition of medically necessary for Medicare?
Services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, under the Social Security Act. In practice, a service is medically necessary when the patient’s record meets the specific criteria in the applicable National or Local Coverage Determination.
What is a Local Coverage Determination?
A policy issued by a regional Medicare Administrative Contractor stating when a particular service or item is covered: the qualifying diagnoses, required clinical findings, documentation and limitations. Most equipment, therapy and many tests are governed by LCDs. They are public in the Medicare Coverage Database.
Why did Medicare deny something my doctor said was necessary?
Almost always because the documentation submitted did not contain the specific elements the coverage policy requires, not because a reviewer disagreed with the doctor. Comparing the policy to the note and adding what is missing, then resubmitting or appealing, resolves most of these.
Does Medicare cover services to maintain function rather than improve it?
Yes. Under the Jimmo v. Sebelius settlement, Medicare coverage of skilled services does not depend on the patient improving. Skilled care needed to maintain function or prevent or slow decline is covered when the skills of a professional are required.
How can a navigator help with medical necessity?
By finding the coverage policy that applies, explaining its requirements to the family and the doctor’s office, helping ensure the visit note and order address each element before the claim is submitted, and coordinating the letter of medical necessity if a denial has to be appealed.
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