Who will make medical decisions as to what is necessary to me: my Doctor or the insurance company?

Question

Bill Wheeler · Accepted Answer

Your doctor is the primary decision-maker for your medical care, making recommendations based on their expertise and what they believe is best for your health and well-being.
Insurance companies determine what tests, drugs, and services they will cover based on their understanding of the types of medical care most patients need.

Gary Church · Answer

I want to answer that question: If you have original Medicare, then it's just you and your doctor. If you have a Medicare Advantage plan, then it's the insurance company’s decision.

Mark Bilgere · Answer

This is one of the most often asked questions when talking about Medicare. Like so many aspects of Medicare there are nuances to the answer. In General, you and your doctor will make decisions regarding your medical treatment. However, depending on the type of Medicare plan you have, there may be input from the insurance company.

If you have a Medicare supplement the Insurance company does not make any decisions regarding your care. If the care is billable to Medicare, the insurance company will pay their part. Keep in mind that Medicare does not pay for everything. Although what it does pay for is quite extensive and providers know what is and isn't covered. The primary things that are not covered are experimental procedures and strictly cosmetic procedures. In addition, dental care, glasses, hearing aids, long term care and assisted living are not paid for by Medicare so therefore are not paid for by a Medicare supplement.

On the other hand, a Medicare Advantage plan does have the right to deny certain procedures or at least ask for additional documentation before agreeing to pay. This is one of the possible cons to an advantage plan. If you run into this situation, don't give up hope. There is an appeal system set up and many people who appeal a denial end up getting the care they are seeking. This is not guaranteed, but it is often worth the effort.

Be sure to work with a trusted broker that will take the time to explain how each plan works and the value each plan has. Remember, cost and price are not always the same thing. Something with a low price could cost you more than you think.

Pamela Masters · Answer

Your doctor decides what you need medically and then he sends it to your insurance for approval. If Medicare covers it, an advantage plan has to cover it as well. If Medicare doesn’t cover it then your Medicare advantage plan won’t cover it either unless it is an ancillary benefit such as dental, vision, hearing or prescription drugs. 
If your advantage plan says it’s not necessary you can appeal the revision

Tony Capraro III · Answer

Medicare Agents Hub is one of the amazing resources for seniors. Have questions or concerns regarding Medicare?

Question: Who will make medical decisions as to what is necessary to inform me, my doctor, or the insurance company?

That is an amazingly good question, and I'm glad you asked. So you have two choices. You can go with Medicare supplement or you can go with Medicare Advantage. You hear all about Advantage all the time. The 800 number is them stuffing your mailboxes with the zero premiums. What they don't tell you is the copays and out-of-pocket costs.

However, I sell both, so I have no bias. It's about what the client wants or needs. We go based on your goals and objectives.

With a Medicare supplement, your doctor and you will make the decision as to what is necessary. With a Medicare Advantage, you have shifted that decision over to the insurance company. So don't be confused. Work with someone like myself or anybody on Medicare Agents Help in your state who's licensed. They can answer all these questions and make things very simple with this Medicare alphabet soup. But great question!

Ronnie Robinson Jr · Answer

If your doctor approves a medical procedure, and you have the proper referrals in place. I have seen decisions made in a reasonable amount of time. Likewise, if none of this is in place, it may be a frustrating process and depend on the plan in place.

Answered by Ronnie Robinson Jr on August 12, 2025

Broker Licensed in FL, AL, GA & 9 other states

Answered by Ronnie Robinson Jr Medicare Insurance Agent

Justin Doherty · Answer

Sadly, the answer to this question is BOTH. Your doctor will primarily decide. However, he will have to stay within the parameters of what your insurance company will cover. For anything outside the normal parameters, he will have to "fight" for you by submitting additional requests and documentation to get the insurance company to approve certain services.

Answered by Justin Doherty on September 26, 2025

Broker Licensed in PA, CO, CT & 11 other states

Answered by Justin Doherty Medicare Insurance Agent

Michael Andrews · Answer

Normally if you have Original Medicare your doctor decides what is Medically necessary as long as it corresponds with Medicare guidelines. Usually there are no referrals or prior authorization requirements needed. If you have a Medicare Advantage plan, a private insurance company is the primary payor for your healthcare and some services may require prior authorization, step therapy, and referrals may be necessary.

Answered by Michael Andrews on August 13, 2025

Broker Licensed in CT

Answered by Michael Andrews Medicare Insurance Agent

Edward MacConnell · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/who-will-make-medical-decisions-as-to-what-is-necessary-to-me-my-doctor-or-the-insurance-company#edward-macconnell

Ryan George · Answer

Short answer: both. 

And that's where it gets frustrating.

Your doctor decides what care is medically appropriate for you. They examine you, know your history, and recommend treatment based on what they believe will help. Your insurance company decides what care they'll pay for. They look at your plan's rules, their coverage guidelines, and whether the service meets their definition of "medically necessary."

Those two answers don't always match. Your doctor can recommend an MRI, a specialist, or a procedure, but if the insurance company decides it doesn't meet their criteria, they can deny the claim or require you to try something cheaper first. That's called prior authorization or step therapy, and it's more common than most people realize.

Here's the part folks miss, a denial isn't the final word. You have the right to appeal, and your doctor can submit documentation to fight for the care they recommended. Plenty of denials get overturned when someone pushes back.

So who's really in charge? Your doctor decides what you need. Your insurance decides what they'll pay for. Your job , and ours, as your broker, is to make sure those two line up as often as possible, and to fight when they don't.

Brady Haffner · Answer

This is not a Medicare directed question. All insurance companies. Decide whether or not you need a certain level of medical help. Ex... if a doctor prescribes you an MRI and the insurance company thinks you’ve had too many MRIs already they will deny MRI and more than likely after the fact. I always review carriers denial percentages, and that is one of an important things about working with brokers that know these items.

Answered by Brady Haffner on February 16, 2026

Broker Licensed in OK

Answered by Brady Haffner Medicare Insurance Agent

Ruben Trejo · Answer

Great question! Your doctor decides what care you need based on your health. The insurance company follows Medicare’s rules to decide what they’ll pay for. So, your doctor makes the medical decisions, and the plan makes sure those services meet Medicare’s coverage guidelines.

Answered by Ruben Trejo on October 27, 2025

Broker Licensed in TX, AL, AR & 44 other states

Answered by Ruben Trejo Medicare Insurance Agent

Allen McGirl · Answer

Ultimately, your doctor is making these decisions. However, it depends on what plan you have and what the procedure is. There are a couple of factors you need to be aware of. Prior authorization and preapprovals within Medicare Advantage plans. Not so much with Original Medicare, but five States as of 2026 are required to use Prior Authorization on some procedures. Reach out to me for more information.

Answered by Allen McGirl on May 12, 2026

Broker Licensed in CO, AL, AZ & 34 other states

Answered by Allen McGirl Medicare Insurance Agent

Sharri Crawford · Answer

Your Doctor is the one who will give you Medical Options as to what you need.  All depending on what procedure it is may request prior approval from your insurance before procedure is done.

Leslie Kaz · Answer

Your doctor recommends the care they believe you need, but your insurance company decides what they will cover based on Medicare’s rules and the plan’s guidelines. In most cases, Medicare or your Medicare Advantage plan follows national coverage rules and medical necessity standards. Sometimes the insurance company may require extra steps—like prior authorization—before covering certain services.

The best approach is for your doctor to clearly document why a service is needed and, if there’s a denial, for you or your doctor to appeal. I can also help guide you through that process so you get the care you need with the least hassle.

Michael Pyers · Answer

Depends on what plan you have.  Advantage plans are mostly managed care and they will make the decision on certain procedures.  Whereas a Medigap Plan would be decided by your physician and medicare.

Kris Moen · Answer

Your doctor is always the one calling the shots medically…
but with Advantage plans, there’s a second opinion sitting behind a desk deciding if they’re going to pay for it.

Michael Roberts · Answer

Your doctor makes the clinical decisions associated with your health care. The insurance company may have clinical review processes referred to as prior authorization to ensure established clinical protocols have been followed and your doctors care plan for you is the financially prudent choice

Answered by Michael Roberts on March 3, 2026

Broker Licensed in NY

Answered by Michael Roberts Medicare Insurance Agent

Clare Goyette · Answer

First your doctor makes a recommendation for a procedure or service and then the Medicare Advantage insurance company has to approve it. Referrals may not get approved or take several submissions to get approved. Original Medicare allows more freedom of access to care.

Answered by Clare Goyette on June 3, 2026

Agent Licensed in FL, GA, MO, NC, SC & VA

Answered by Clare Goyette Medicare Insurance Agent

Chuck Winderl · Answer

Your doctor is the one who will make your Medicare treatment decisions. As part of the application process for a Humana Medicare Advantage we need to know who your doctors are and the drugs you are on so we can offer a Medicare advantage plan that you doctor is listed on and then the plan will accept the doctor's treatment decision.

Answered by Chuck Winderl on October 19, 2025

Agent Licensed in OH

Answered by Chuck Winderl Medicare Insurance Agent

Mary Brown · Answer

Your doctor decides what care is medically necessary, but coverage rules affect payment: Original Medicare and Medigap follow your doctor, while Medicare Advantage (HMO/PPO) may require prior authorization or network restrictions.

Answered by Mary Brown on March 30, 2026

Broker Licensed in NJ, DE, FL & NC, OH, PA & TX

Answered by Mary Brown Medicare Insurance Agent

Patricia Graham · Answer

Medicare provides a list of covered procedures, which can also depend on doctors and insurance companies. I find this can be tricky for people.

Jose Felix Arevalo · Answer

Your doctor is the one who decides what care you medically need, tests, treatments, medications, and follow‑ups. That part is purely clinical.
Your insurance company doesn’t make medical decisions, but they do decide what it will pay for based on your plan rules, prior authorization requirements, and Medicare guidelines.

So the doctor determines the care, and the insurance company determines the coverage.

Angelina Watkins · Answer

Your doctor can determine what your medical needs are and it is the responsibility of the doctor to be able to provide the information to the insurance company as to why something the insurance company does not cover should be covered as medically necessary.

Answered by Angelina Watkins on November 17, 2025

Agent Licensed in OH, FL, GA & 5 other states

Answered by Angelina Watkins Medicare Insurance Agent

Stephanie Floyd · Answer

Your doctor is the one who decides what care you medically need, tests, treatments, medications, and follow‑ups. That part is purely clinical.

Your insurance company doesn’t make medical decisions, but they do decide what it will pay for based on your plan rules, prior authorization requirements, and Medicare guidelines.

So the doctor determines the care, and the insurance company determines the coverage.

Michael Murray · Answer

All medical decisions should be made by you or the people in your life who matter most, that can be your Power of Attorney, your children and your spouse. Only you know what is best for you and by disclosing that to your Medicare agent they can help guide you to the right coverage!

Answered by Michael Murray on March 30, 2026

Agent Licensed in NC, SC & TN

Answered by Michael Murray Medicare Insurance Agent

Parris Brady · Answer

When it comes to “medical decisions,” you should always follow your doctor’s advice. Insurance Companies are experts in insurance not medical. Doctors are the experts when it comes to medical advice.

Answered by Parris Brady on August 13, 2025

Broker Licensed in FL, AZ, CA & 18 other states

Answered by Parris Brady Medicare Insurance Agent

Maxine Rosen · Answer

This is a very important question to understand. 

You, should be able to make your own decisions based on  consultation with your doctor. 

But if the doctor disagrees, get a second opinion. 

If the health plan denies the need, escalate the request. 

I have had clients who needed to post on social media the disastrous answers their health plan gave. 

Finally, it is inportant to have a Durable Medical Power of Attorney in the event you need someone to step up and help to protect you.

Jerry Naylor · Answer

The doctor makes medical decisions. We try to work with insurance providers up from to ensure you have the best coverage with in network doctors as needed based on your medical circumstances.

Who will make medical decisions as to what is necessary to me: my Doctor or the insurance company?

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Who will make medical decisions as to what is necessary to me: my Doctor or the insurance company?

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