Non-Covered Services - JE Part B

Medical necessity is defined as services that are reasonable and necessary for diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.

Medicare covers services it views as medically necessary to diagnose or treat health conditions. If those conditions produce debilitating symptoms or side effects it would also be considered medically necessary to treat those as well.

To be considered medically necessary, items and services must meet certain qualifications:

• Consistent with symptoms or diagnosis of illness or injury under treatment
• Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational)
• Not furnished primarily for convenience of patient, attending physician or other physician or supplier
• Furnished at most appropriate level that can be provided safely and effectively to patient

Services also need to meet criteria provided in the Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). These determinations are decided by CMS and Medicare contractors to determine if Medicare will pay for a specific item or service, or if additional rules apply to make payment. Not every procedure code has an NCD or LCD policy attached to it. If there is not a clear coverage policy available, providers should focus on "what constitutes medical necessity."

Non-Covered vs Statutorily Excluded

Non-Covered: An item or service may be non-covered if the coverage criteria are not met per the NCD or LCD; it would be considered not reasonable or necessary. For these services that do not meet policy criteria, a mandatory Advance Beneficiary Notice of Noncoverage (ABN) is required with the GA modifier appended upon claim submission.

Statutorily Excluded: These items are excluded by statute and not recognized as part of a covered Medicare benefit. A voluntary ABN may be given and the claim is submitted with the GY modifier, indicating the voluntary ABN.

• Dental: Items and services in connection with care, treatment, filling, removal or replacement of teeth or structures directly supporting teeth
  • Examples: Preparation of mouth for dentures or removal of diseased teeth in an injected jaw; X-ray taken in connection with care or treatment of teeth or periodontium
  • Exceptions that May Be Covered: Some dental services may be covered depending upon whether primary procedure that the dentist performs is covered. Also, if Medicare makes payment for a covered dental procedure, Medicare will pay no matter where service is performed. Examples:
    • X-ray taken in connection with reduction of a fracture of jaw or facial bone; however, however, a single x-ray or x- ray survey taken in connection with care or treatment of teeth or periodontium is not covered
    • Tooth extraction performed to prepare jaw for radiation treatments of neoplastic disease. This is covered because purpose of examination is not for care of teeth or structures directly supporting teeth
    • Reconstruction of jaw following an injury from an accident
    • Examples:
      • Treatment of flat foot
      • Routine foot care such as cutting or removal of corns and calluses, trimming, cutting, clipping or debriding of nails and other hygienic and preventive maintenance care
      • Supportive devices for feet
      • Orthopedic shoes that are an integral part of a leg brace and its expense is included as part of brace cost
      • Therapeutic shoes furnished to diabetics
      • Treatment of warts on foot, including plantar warts. This is covered to same extent as services provided for treatment of warts located anywhere else on body
      • Services that are a necessary and integral part of an otherwise covered service
      • Exceptions that May Be Covered:
        • Repair of an accidental injury or improvement of functioning of a malformed body member may be covered
        • Surgery performed in connection with treatment of severe burns
        • Surgery to repair face following a serious automobile accident
        • Surgery for therapeutic purposes that may coincidentally also serve some cosmetic purpose
        • Exceptions that May Be Covered: Certain devices that produce perception of sound by replacing function of middle ear, cochlea or auditory nerve are payable by Medicare as prosthetic devices. These devices are indicated only when hearing aids are medically inappropriate or cannot be used due to congenital malformations, chronic disease, severe sensorineural hearing loss or surgery
        • Examples when furnished in beneficiary's home or an institution:
          • Walking
          • Getting in and out of bed
          • Bathing
          • Dressing
          • Feeding
          • Using the toilet
          • Preparing special diet
          • Supervising administration of medication that can usually be self-administered
          • Medicare covers only medically necessary, skilled care and may cover at-home custodial care only if it is provided in conjunction with skilled care. For example, care furnished to a beneficiary who elected hospice care only if it is not reasonable and necessary for treatment of the terminal illness and related conditions
          • Examples:
            • Radios
            • Televisions
            • Beauty and barber services such as manicures or hairstyling
            • Basic personal services, such as simple barber and beautician services (e.g., shaves, haircuts, shampoos, and simple hair sets), that a patient needs and cannot perform for themselves. These may be viewed as ordinary patient care when furnished by a long-stay institution. Such services are covered costs reimbursable under Part A when included in flat rate charge and provided routinely without charge to patient by a Skilled Nursing Facility (SNF) or by a general psychiatric or tuberculosis hospital
            • Exceptions that May Be Covered:
              • The VA may authorize non-Federal providers or private physicians or other suppliers to render services at Federal expense. The VA may pay for treatment of veterans in non-VA hospitals for service-connected disabilities and, in certain circumstances, for nonservice-connected disabilities, provided VA has given prior authorization for the services. This is known as Fee Basis services
              • Examples:
                • Eye examinations for prescribing, fitting or changing eyeglasses
                • For the most part Immunizations (with exceptions)
                • Physical examinations performed without a specific sign symptom or required by third parties
                • Physician services performed in conjunction with an eye
                • Vaccinations specifically covered by statute, such as seasonal influenza virus, pneumococcal and Hepatitis B
                • Vaccinations directly related to treatment of an injury or exposure to disease such as anti-rabies treatment
                • Screening mammography
                • Colorectal cancer screening tests
                • Diabetes screenings
                • Screening electrocardiogram
                • Prostate cancer screening
                • Initial Preventive Physical Examination (IPPE)
                • Annual Wellness Visit (AWV)

                Resources

                • Additional Information Required for Coverage and Pricing for Category III CPT Codes Coverage Article
                • Non-Covered Service Local Coverage Determination (LCD)
                • CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15
                • CMS IOM, Publication 100-02, Chapter 16
                • CMS Items and Services Not Covered Under Medicare
                Last Updated Oct 26 , 2022

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