What are the major "medical necessity " conditions which Medicare
cites to deny hospital payment claims for < 30 days readmissions ?

---

Request for Question Clarification by missy-ga on 07 May 2002 13:18 PDT

Hi Maury, 

As you can well imagine, there are vast numbers of websites dealing
with Medicare coverage.  Looking at a few of those and realizing that
the regulations are quite complex, I thought it best to contact
Medicare directly (1-800-MEDICARE).

The Medicare representative told me that what is considered a "medical
necessity" is complex and varies dependent upon your condition and
your treatment.

Each time your hospital or physician submits a claim, you should
receive a "Medicare Summary Notice", which will explain what was paid
for and what wasn't.  In the upper right hand of your summary is a
telephone number for your "fiscal intermediary" - if you call that
number, they will be able to explain each line, and explain how to
appeal any decision you disagree with.

If you could provide a little more detail, I could dig through the
Medicare regulations for you, but as your question stands, I'm afraid
any information I might find would be inadequate, inaccurate or
completely inapplicable to your situation.

If you were able to give the cpt codes for your treatment I would be
able to give a detailed answer. Unfortunately Medicare has different
medical neccesities for different medical treatments. They are on a
case by case basis. Please forgive me if this sounds repetitive.