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Exclusions from Coverage and Medicare as Secondary Payer

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42 USCS § 1395y

Current through PL 116-8, approved 3/8/19

United States Code Service - Titles 1 through 54 > TITLE 42. THE PUBLIC HEALTH AND WELFARE > CHAPTER 7. SOCIAL SECURITY ACT > TITLE XVIII. HEALTH INSURANCE FOR THE AGED AND DISABLED > PART E. MISCELLANEOUS PROVISIONS

§ 1395y. Exclusions from coverage and medicare as secondary payer [Caution: See prospective amendment note below.]

(a) Items or services specifically excluded. Notwithstanding any other provision of this title [42 USCS §§ 1395 et ], no payment may be made under part A or part B [42 USCS §§ 1395c et seq. or 1395j et seq.] for any expenses incurred for items or services--

(1)(A) which, except for items and services described in a succeeding subparagraph or additional preventive services (as described in section 1861(ddd)(1) [42 USCS § 1395x(ddd)(1)]), are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,

in the case of items and services described in section 1861(s)(10) [42 USCS § 1395x(s)(10)], which are not reasonable and necessary for the prevention of illness,

(B) in the case of hospice care, which are not reasonable and necessary for the palliation or management of terminal illness,

(C) in the case of clinical care items and services provided with the concurrence of the Secretary and with respect to research and experimentation conducted by, or under contract with, the Medicare Payment Advisory Commission or the Secretary, which are not reasonable and necessary to carry out the purposes of section 1886(e)(6),

(D) in the case of research conducted pursuant to section 1142 [42 USCS § 1320b-12], which is not reasonable and necessary to carry out the purposes of that section,

(E) in the case of screening mammography, which is performed more frequently than is covered under section 1834(c)(2) [42 USCS § 1395m(c)(2)] or which is not conducted by a facility described in section 1834(c)(1)(B) [42 USCS § 1395m(c)(1)(B)], in the case of screening pap smear and screening pelvic exam, which is performed more frequently than is provided under section 1861(nn) [42 USCS § 1395x(nn)], and, in the case of screening for glaucoma, which is performed more frequently than is provided under section 1861(uu) [42 USCS § 1395x(uu)],

(F) in the case of prostate cancer screening tests (as defined in section 1861(oo)), which are performed more frequently than is covered under such section,

(G) in the case of colorectal cancer screening tests, which are performed more frequently than is covered under section 1834(d) [42 USCS § 1395m(d)],

(H) the frequency and duration of home health services which are in excess of normative guidelines that the Secretary shall establish by regulation,

(I) in the case of a drug or biological specified in section 1847A(c)(6)(C) [42 USCS § 1395w- 3a(c)(6)(C)] for which payment is made under part B [42 USCS §§ 1395j et seq.] that is furnished in a competitive area under section 1847B [42 USCS § 1395w-3b], that is not furnished by an entity under a contract under such section,

(J) in the case of an initial preventive physical examination, which is performed more than 1 year after the date the individual's first coverage period begins under part B [42 USCS §§ 1395j et ],

(K) in the case of cardiovascular screening blood tests (as defined in section 1861(xx)(1) [42 USC1395x(xx)(1)]), which are performed more frequently than is covered under section 1861(xx)(2) [42 USCS § 1395x(xx)(2)],

(L) in the case of a diabetes screening test (as defined in section 1861(yy)(1) [42 USCS § 1395x(yy)(1)]), which is performed more frequently than is covered under section 1861(yy)(3) [42 USCS § 1395x(yy)(3)],

(M) in the case of ultrasound screening for abdominal aortic aneurysm which is performed more frequently than is provided for under section 1861(s)(2)(AA) [42 USCS § 1395x(s)(2)(AA)],

(N) in the case of kidney disease education services (as defined in paragraph (1) of section 1861(ggg) [42 USCS § 1395x(ggg)]), which are furnished in excess of the number of sessions covered under paragraph (4) of such section, and

(O) in the case of personalized prevention plan services (as defined in section 1861(hhh)(1) [42 USCS § 1395x(hhh)(1)]), which are performed more frequently than is covered under such section; 

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Source: The Centers for Medicare and Medicaid Services

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