THE FOUR CATEGORIES OF ITEMS AND SERVICES THAT ARE NOT COVERED UNDER THE MEDICARE PROGRAM AND APPLICABLE EXCEPTIONS
The following four categories of items and services that are not covered under the Medicare Program are discussed in this publication:
1)Services and supplies that are not medically reasonable and necessary;
2)Non-covered items and services;
3)Services and supplies that have been denied as bundled or included in the basic allowance of
another service; and
4) Items and services reimbursable by other organizations or furnished without charge.
Where applicable, exceptions (items and services that may be covered) are also included in this discussion.
1) Services and Supplies That Are Not MedicallyReasonable and Necessary
Services and supplies that are not medically reasonable and necessary to the overall diagnosis and treatment of the beneficiary’s condition will not be covered. Some examples include:
• 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
• 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 under Exceptions;
• Services not warranted based on the diagnosis of the beneficiary (for example, acupuncture and
transcendental meditation); and
• Items and services administered to a beneficiary for the purpose of causing or assisting in causing death (assisted suicide).
In general, Medicare-covered services are those services considered medically reasonable and necessary to the overall diagnosis or treatment of the beneficiary’s condition or to improve the functioning of a malformed body member. Services or supplies are considered medically necessary if they meet the standards of good medical practice and are:
• Proper and needed for the diagnosis or treatment of the beneficiary’s medical condition;
• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition; and
• Not mainly for the convenience of the beneficiary, provider, or supplier.
Services must also meet specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations. For every service billed, you must indicate the specific sign, symptom, or beneficiary complaint necessitating the service. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment
for services without beneficiary symptoms or complaints or specific documentation.
• Annual Wellness Visit;
• Initial Preventive Physical Examination (also known as the “Welcome to Medicare Preventive
• 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);
• 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; and
• Screening for sexually transmitted infections (STI) and high intensity behavioral counseling
to prevent STIs. Items and services administered for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, may be covered provided they are not furnished for the specific purpose of causing death.
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