Items and Services Not Covered Under Medicare
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Items and Services Not Covered Under Medicare
ICN 906765 January 2017
PREFACE
This publication provides information on the four categories of items and services not covered under Medicare and applicable exceptions (items and services that may be covered). The discussion is not intended to provide an all-inclusive list of all items and services Medicare may or may not cover.
Please note: Any item or service furnished directly or indirectly by an individual or entity excluded by the Office of Inspector General from participating in all Federal health care programs is a non-covered item or service pursuant to Section 1862(e) of the Social Security Act.
When “you” is used in this publication, we are referring to Medicare providers and suppliers.
THE FOUR CATEGORIES OF ITEMS AND SERVICES NOT COVERED UNDER MEDICARE AND APPLICABLE EXCEPTIONS
Learn about these four categories of items and services not covered under Medicare:
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Source: The Centers for Medicare and Medicaid Services
- Services and supplies that are not medically reasonable and necessary
- Non-covered items and services
- Services and supplies denied as bundled or included in the basic allowance of another service
- Items and services reimbursable by other organizations or furnished without charge
- Services furnished in a hospital that, based on the beneficiary’s condition, could have been furnished in a lower-cost setting (for example, the beneficiary’s home or a nursing home)
- Hospital services that exceed Medicare length of stay limitations
- Evaluation and management services that exceed those considered medically reasonable and necessary
- Therapy or diagnostic procedures that exceed Medicare usage limits
- Screening tests, examinations, and therapies for which the beneficiary has no symptoms or documented conditions, with the exception of certain screening tests, examinations, and therapies as described below under Exceptions (Items and Services That May Be Covered)
- Services not warranted based on the diagnosis of the beneficiary (for example, acupuncture and transcendental meditation)
- Items and services administered to a beneficiary for the purpose of causing or assisting in causing death (assisted suicide)
- Annual Wellness Visit
- Initial Preventive Physical Examination (also known as the “Welcome to Medicare Preventive Visit”)
- Colorectal cancer screening
- Screening mammography
- Clinical breast examinations
- Screening Pap tests
- Screening pelvic examinations
- Prostate cancer screening
- Cardiovascular disease screenings
- Diabetes screening tests
- Glaucoma screening
- Human Immunodeficiency Virus (HIV) screening
- Bone mass measurements
- Medical nutrition therapy (for certain beneficiaries diagnosed with diabetes, renal disease, or who have received a kidney transplant within the last 3 years)
- Diabetes Self-Management Training (for beneficiaries diagnosed with diabetes)
- Vaccines
- Ultrasound screening for abdominal aortic aneurysm
- Intensive behavioral therapy for cardiovascular disease
- Intensive behavioral therapy for obesity
- Counseling to prevent tobacco use for asymptomatic beneficiaries
- Screening for depression
- Screening and behavioral counseling interventions in primary care to reduce alcohol misuse
- Screening for sexually transmitted infections (STI) and high intensity behavioral counseling to prevent STIs
- Screening for Hepatitis C virus
- Screening for lung cancer
- Transitional Care Management
- Chronic Care Management
- Advance Care Planning
- The 50 States
- The District of Columbia
- The Commonwealth of Puerto Rico
- The U.S. Virgin Islands
- Guam
- The Commonwealth of the Northern Mariana Islands
- American Samoa
- Territorial waters adjoining the land areas of the U.S. (for services furnished on board a ship)
- Emergency inpatient hospital services furnished at a foreign hospital provided the foreign hospital is closer to, or more accessible from, the place the emergency arose than the nearest U.S. hospital that is adequately equipped and available to deal with the emergency. One of these conditions must also exist:
- The beneficiary was physically present in the U.S. at the time of the emergency.
- The beneficiary was physically present in Canada when the emergency arose, and he or she was traveling by the most direct route without unreasonable delay between Alaska and another State.
- Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the S. provided the hospital is closer to, or substantially more accessible from, the beneficiary’s U.S. residence than the nearest participating U.S. hospital that is adequately equipped to deal with and available to treat the illness or injury.
- Physician and ambulance services furnished in connection with covered foreign inpatient hospital services when these criteria are met:
- The physician is legally authorized to practice in the country where he or she furnishes the services.
- The ambulance supplier meets Medicare’s definition of an ambulance.
- Services furnished on board a ship in a U.S. port or furnished within 6 hours of when the ship arrived at or departed from a U.S.
- Radios
- Televisions
- Beauty and barber services, except as described below under Exceptions (Items and Services That May Be Covered)
- Shaves
- Haircuts
- Shampoos
- Simple hair sets
- Furnished by a long-stay institution
- Included in the flat rate charge
- Routinely furnished without charge to the beneficiary
- Routine or annual physical checkups, except as described in the Exceptions (Items and Services That May Be Covered) Section under 1) Services and Supplies That Are Not Medically Reasonable and Necessary
- Physical examinations performed without a specific sign, symptom, or beneficiary complaint necessitating the service or required by third parties (for example, insurance companies, business establishments, or Government agencies)
- Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses
- Eye refractions furnished by all practitioners for any purpose
- Eyeglasses and contact lenses
- Examinations for hearing aids
- Hearing aids
- Immunizations, except as described in the Exceptions (Items and Services That May Be Covered) Section under 1) Services and Supplies That Are Not Medically Reasonable and Necessary
- Physician services performed in conjunction with an eye disease (for example, glaucoma and cataracts)
- Services performed “incident to” physician services in conjunction with an eye disease
- One pair of eyeglasses or contact lenses after each cataract surgery with insertion of an intraocular lens
- Vaccinations directly related to the treatment of an injury or direct exposure to a disease or condition (for example, antirabies treatment and immune globulin)
- Vaccinations specifically covered by statute (for example, seasonal influenza virus, pneumococcal, and Hepatitis B)
- A reasonable supply of antigens (not more than a 12-week supply prepared for a particular beneficiary) a doctor of medicine (MD) or a doctor of osteopathy (DO) prepares after examining the beneficiary and determining a plan of treatment and dosage regimen
- Certain devices that produce perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve and are indicated only when hearing aids are medically inappropriate or cannot be utilized due to:
- Congenital malformations
- Chronic disease
- Severe sensorineural hearing loss
- Surgery
- Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or the auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays
- Osseointegrated implants that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer
- Walking
- Getting in and out of bed
- Bathing
- Dressing
- Feeding
- Using the toilet
- Preparing a special diet
- Supervising the administration of medication that can usually be self-administered
- Surgery performed in connection with the treatment of severe burns
- Surgery to repair the face following a serious automobile accident
- Surgery for therapeutic purposes that may coincidentally also serve some cosmetic purpose
- Husband or wife
- Natural or adoptive parent, child, or sibling
- Stepparent, stepchild, stepbrother, or stepsister
- Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law
- Grandparent or grandchild
- Spouse of grandparent or grandchild
- Individuals who are related by blood, marriage, or adoption
- Domestic employees
- Other individuals who live together as part of a single family unit (does not include roomers or boarders)
- Charges for services furnished by a physician or supplier with a prohibited relationship to the beneficiary submitted by an unrelated individual, partnership, or professional corporation
- Those services furnished “incident to” a physician’s professional service when the ordering or supervising physician has a prohibited relationship to the beneficiary
- Completely owned by one or more physicians or is owned by other health care professionals as authorized by State law
- Operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic
- The gingivae
- The dentogingival junction
- The periodontal membrane
- The cementum
- The alveolar process
- An x-ray that is taken in connection with the reduction of a fracture of the jaw or facial bone
- A tooth extraction that is performed to prepare the jaw for radiation treatments of neoplastic disease
- Physician services furnished to hospital inpatients and SNF residents (with the exception of therapy in SNFs, which must be provided by the SNF itself, either directly or under arrangement, to both its Part A and Part B inpatients)
- Physician assistant services
- Nurse practitioner services
- Clinical nurse specialist services
- Certified nurse-midwife services
- Qualified clinical psychologist services
- Certified registered nurse anesthetist services
- Home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies (including related necessary ambulance services)
- Epoetin Alfa (EPO) for certain dialysis patients
- Hospice care related to a beneficiary’s terminal condition
- Radioisotope services
- Some customized prosthetic devices
- Some chemotherapy and chemotherapy administration services
- These categories of exceptionally intensive outpatient services (along with transportation from the SNF to the hospital and back when the resident’s medical condition requires the use of an ambulance) are beyond the typical scope of SNF care plans as to require the intensity of the hospital setting to be furnished safely and effectively (accordingly, this exception does not apply if these services are furnished in a freestanding [non-hospital] setting):
- Cardiac catheterization
- Computerized axial tomography scans
- Magnetic resonance imaging
- Ambulatory surgery that involves the use of an operating room or comparable setting
- Radiation therapy services
- Angiography
- Certain lymphatic and venous procedures
- Emergency services
- Treatment of flat foot
- Routine foot care, which includes
- The cutting or removal of corns and calluses
- The trimming, cutting, clipping, or debriding of nails
- Other hygienic and preventive maintenance care (for example, cleaning and soaking the feet, use of skin creams to maintain skin tone of either ambulatory or bedridden patients, and any other service performed in the absence of localized illness, injury, or symptoms involving the foot)
- Orthopedic shoes and other supportive devices for the feet
- Treatment of mycotic nails:
- For an ambulatory beneficiary, the physician attending the mycotic condition must document that:
- There is clinical evidence of mycosis of the toenail
- The beneficiary has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate
- For an ambulatory beneficiary, the physician attending the mycotic condition must document that:
- Treatment of warts on the foot (including plantar warts)
- Services that are a necessary and integral part of an otherwise covered service (for example, the diagnosis and treatment of ulcers, wounds, or infections)
- Therapeutic shoes furnished to diabetics
- Orthopedic shoes that are an integral part of a leg brace
- For a non-ambulatory beneficiary, the physician attending the beneficiary’s mycotic condition must document that:
- There is clinical evidence of mycosis of the toenail
- The beneficiary suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate
- Presence of a systemic condition such as one of these metabolic, neurologic, and peripheral vascular diseases (this is not an all-inclusive list):
- Diabetes mellitus*
- Arteriosclerosis obliterans
- Buerger’s disease
- Chronic thrombophlebitis*
- Peripheral neuropathies that involve the feet:
- Associated with malnutrition and vitamin deficiency:*
- Malnutrition (general, pellagra)
- Alcoholism
- Malabsorption (celiac disease, tropical sprue)
- Pernicious anemia
- Associated with carcinoma*
- Associated with diabetes mellitus*
- Associated with drugs and toxins*
- Associated with multiple sclerosis*
- Associated with uremia (chronic renal disease)*
- Associated with traumatic injury
- Associated with leprosy or neurosyphilis
- Associated with hereditary disorders:
- Hereditary sensory radicular neuropathy
- Angiokeratoma corporis diffusum (Fabry’s)
- Amyloid neuropathy
- Associated with malnutrition and vitamin deficiency:*
- Cosmetic surgery
- Non-covered organ transplants
- Services related to follow-up care or complications that require treatment during a hospital stay in which a non-covered service is performed
- Repair of complications after transsexual or cosmetic surgery
- Treatment of an infection at the surgical site of a non-covered service
- Fragmented services included in the basic allowance of the initial service
- Prolonged care (indirect)
- Physician standby services
- Case management services (for example, telephone calls to and from the beneficiary)
- Supplies included in the basic allowance of a procedure
- Services Reimbursable Under Automobile, No-Fault, or Liability Insurance or Workers’ Compensation (WC) (the Medicare Secondary Payer Program)
- Automobile insurance
- No-fault insurance
- Liability insurance
- WC law or Plan of the U.S. or a State
- The Group Health Plan denies payment for services because:
- The beneficiary is not covered by the health plan
- Benefits under the plan are exhausted for particular services
- The services are not covered under the plan
- A deductible applies
- The beneficiary is not entitled to benefits
- The no-fault or liability insurer denies payment or does not pay the bill because benefits have been exhausted
- The WC Plan denies payment (for example, when it is not required to pay for certain medical conditions)
- The Federal Black Lung Program does not pay the bill
- The claim is not expected to be paid promptly
- A properly submitted claim was denied in whole or in part
- A proper claim has not been filed with the primary insurer due to the beneficiary’s physical or mental incapacity
- Those furnished by a Government or non-Government provider or other individual at public expense pursuant to an authorization issued by a Federal agency (for example, Veterans Administration authorized services).
- Those furnished by a Federal provider or agency that generally provides services to the public as a community institution or agency (hospitals, SNFs, Home Health Agencies, and Comprehensive Outpatient Rehabilitation Facilities are not included in this category). Federal hospitals, like other nonparticipating hospitals, may be paid for emergency inpatient and outpatient hospital services.
- Those that a Federal, State, or local Government entity directly or indirectly pays for or furnishes without expectation of payment from any source and without regard to the individual’s ability to pay.
- Those that a non-Government provider or supplier furnishes and the charges are paid by a Government program other than Medicare or where the provider or supplier intends to look to another Government program for payment (unless the payment by the other program is limited to Medicare deductible and coinsurance amounts).
- X-rays or immunizations gratuitously furnished to the beneficiary without regard to his or her ability to pay and without expectation of payment from any source.
- An ambulance transport provided by a volunteer ambulance If the ambulance company asks but does not require a donation from the beneficiary to help offset the cost of the service, there is no enforceable legal obligation for the beneficiary or any other individual to pay for the service.
- When a replacement from another manufacturer is substituted because the replacement offered under the warranty is not acceptable to the beneficiary or to the beneficiary’s physician
- Partial payment, if defective equipment or medical devices are supplied by the warrantor and a charge or a pro rata payment is imposed
- Payment is limited to the amount that would have been paid under the warranty if an acceptable replacement could have been purchased at a reduced price under a warranty, but the full price was paid to the original manufacturer or a new replacement was purchased from a different manufacturer or other source
For More Information About… | Resource |
Services Not Covered Under Medicare and Medicare-Covered Services | Chapters 1, 6, 8, 9, 15, and 16 of Medicare Benefit Policy Manual (Publication 100-02) Medicare National Coverage Determinations (NCD) Manual (Publication 100-03) |
Medicare Secondary Payer | Medicare Secondary Payer Manual (Publication 100-05) |
Claims Processing Procedures for Non-Covered Services | Medicare Claims Processing Manual (Publication 100-04) |
Preventive Services | Preventive Services Chapter 15 of the Medicare Benefit Policy Manual (Publication 100-02) |
ABNs | Chapter 30 of the Medicare Claims Processing Manual (Publication 100-04) Beneficiary Notices Initiative (BNI) |
All Available Medicare Learning Network® (MLN) Products | MLN Catalog |
Provider-Specific Medicare Information | MLN Guided Pathways: Provider Specific Medicare Resources |
Medicare Information for Beneficiaries | Medicare.gov |