Medicare, Medicaid, or other federally funded programs will pay only for tests that meet their coverage criteria and are reasonable and necessary to treat or diagnose a patient. These programs do not pay for tests for which the patient record does not support that the tests were reasonable and necessary.

Medicare generally does not cover routine screening tests even if the physician or individuals authorized by law to order tests considers the tests appropriate for the patient.

42 U.S.C. § 1395y(a)(1)(A) of the Federal Register prohibits Medicare and Medicaid from reimbursing for items or services which are not reasonable or necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Laboratories are required to provide annual notice of these restrictions to physicians and other individuals ordering laboratory services. Below you will find electronic copies of those notices.

                         PDF Icon    2018 OIG Annual Physician Notice