Medicare Coverage Guidance

Medicare coverage and payment is contingent upon a determination that:

  • A service is in a covered benefit category
  • A service is not specifically excluded from Medicare coverage by the Social Security Act
  • The item or service is “reasonable and necessary” for the diagnosis or treatment of an illness or injury, to improve functioning of a malformed body member, or is a covered preventive service

These criteria are codified through rulemaking in the Code of Federal Regulations and/or applied in manual guidance, or are applied through coverage determinations. The Medicare Managed Care Manual Chapter 4 delineates Medicare Advantage Benefits and Beneficiary Protections and specifically Section 90 provides guidance on Coverage Determinations.

We defer to Centers for Medicare and Medicaid Services (CMS) guidelines for coverage positions for our Medicare Advantage (HMO and PPO) lines of business. CMS guidance takes precedence, where no Medicare guidelines exist, we will defer to the existing commercial medical policy. Commercial Medical Injectable Policies do not apply.

For Medicare services that require preauthorization administered by independent companies on behalf of Capital Blue Cross: