ROUTINE NOTICE PROHIBITION
Providers are prohibited from issuing ABNs on a routine basis (i.e., where there is no reasonable expectation of non-coverage). Providers will not violate the routine notice prohibition solely on the basis of the number of ABNs issued as long as there is a reasonable basis for issuing an ABN.
TO WHOM SHOULD AN ABN BE GIVEN?
The Medicare beneficiary.
The Medicare beneficiary’s representative under applicable state or other law. A representative is an individual who may make health care and financial decisions on a beneficiary’s behalf (e.g., legal guardian or someone appointed according to a properly executed “durable medical power of attorney”).
REASONS FOR NON-COVERAGE
Services denied by the Medicare program as not medically necessary or reasonable fall into these general categories:
Experimental and investigational.
Not safe and effective.
Limited coverage based on certain criteria.
Number of services exceeds the norm and no medical necessity demonstrated for the extra number of services.