Medicare will only pay for services it determines to be “reasonable and necessary”
under section 1862 (a) (1) of the Medicare law. If Medicare determines that a particular service, although
it would otherwise be covered, is “not reasonable and necessary” under Medicare program standards, Medicare will
deny payment for that service. I believed that, in your case, Medicare is likely to deny payment for:
____________________________ for the following reasons:_____________________________
Beneficiary Agreement
I have been notified by my physician that he or she believes that, in my case,
Medicare is likely to deny payment for the services identified above for the reasons stated.
If Medicare denies payment, I agree to be personally and fully responsible for payment.
Signature of Medicare Beneficiary:_________________________
Date:____________________
