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]