Medical Necessity

What is Medical Necessity?

Medicare has guidelines that may limit coverage based on diagnosis or
frequency (how often the test is ordered).

In Medicare terms, “not medically necessary” simply means that the service
is not a benefit for this diagnosis or at this frequency. Your treating provider will be the best source for discussion of why this procedure or service is medically indicated for you.

What is an ABN Form?

• The ABN indicates that Medicare will probably deny payment for the test and tells you the reason, as well as the estimated cost of the service which you will need to pay.
• It allows you the opportunity to accept or refuse the service and protects you from unexpected expenses if Medicare denies payment.
• It also offers you the right to appeal Medicare’s decision.

But I’ve had this Test in the Past – What’s Changed?

In order to ensure that we’re compliant with Medicare rules, this is a new
policy at Rutland Regional Medical Center.

How do I Contact Medicare to ask Questions about my Coverage?

• Medicare has a website: www.medicare.gov
• Medicare toll-free phone number: 800.633.4227

Your provider is the best resource for information. Please contact their office to discuss the test and possible financial liability.