Implementations of doctrine[edit]

Medicare[edit]

Medicare pays for medical items and services that are "reasonable and necessary" or "appropriate" for a variety of purposes.[1] By statute, Medicare may pay only for items and 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" unless there is another statutory authorization for payment.[2]


Medicare has a number of policies that describe coverage criteria, including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs),[3] formerly known as Local Medical Review Policies (LMRP).[note 1]


In a small number of cases, Medicare may determine if a method of treating a patient should be covered on a case-by-case basis. Even if a service is medically determined to be "reasonable and necessary," coverage may be limited if the service is provided more frequently than allowed under Medicare coverage policies.[note 2]

(CMN)

Certificate of medical necessity

from medicare.gov

Your Medicare Coverage

which includes NCDs, LMRP/LCDs, as well as NCAs & CALs, from cms.hhs.gov

Medicare Coverage Database

at cms.hhs.gov

Physician Fee Schedule lookup

at academia.edu, by Daniel R. Skinner, published in the journal Public Administration Review (2013).

Defining Medical Necessity Under the Patient Protection and Affordable Care Act

by Daniel Skinner, a book published by the University of Minnesota Press (2019).

Medical Necessity: Health Care Access and the Politics of Decision Making

Charles Martin, "Medical Use of Cannabis in Australia: 'Medical necessity' defences under current Australian law and avenues for reform" (2014) 21(4) Journal of Law and Medicine 875.

by Miami attorney Jared H. Beck

Florida's Medical Necessity Defense, Reconsidered