Why Medicare Has Not Established Criteria for Coverage Decisions

Abstract

Decisions about medical coverage by Medicare specify the forms of technology and services that the program will pay for on behalf of its 42 million beneficiaries. These decisions often have far-reaching effects through their influence on the policies of other public and private payers in determining medical necessity. For the nearly four decades since Medicare was created in 1965, coverage decisions have been based on section 1862(a)(1)(A) of the statute that enacted the program: “Notwithstanding any other provision of this title, no payment may be made . . . for any expenses incurred for items or services which . . . . .