NOT COVERED ITEMS AND SERVICE UNDER THE MEDICARE PROGRAM AND APPLICABLE EXCEPTIONS
(2) Non-Covered Items and Services
A) Custodial Care
Custodial care furnished in the beneficiary’s home or an institution is not covered. Custodial care is
personal care that does not require the continuing attention of trained medical or paramedical
personnel and serves to assist an individual in the activities of daily living. The following activities are
considered custodial care:
• Getting in and out of bed;
• Using the toilet;
• Preparing a special diet; and
• Supervising the administration of medication that can usually be self-administered.
Individual reasonable and necessary services may be covered under Part B even though Part A denies coverage of a beneficiary’s overall hospital or SNF stay because it is determined to be
custodial.Care furnished to a beneficiary who has elected the hospice care option is considered custodial only if it is not reasonable and necessary for the palliation or management of the terminal illness and related conditions.
B) Cosmetic Surgery
Cosmetic surgery and expenses incurred in connection with cosmetic surgery are not covered.
Cosmetic surgery includes any surgical procedure directed at improving the beneficiary’s appearance.
The prompt (as soon as medically feasible) repair of an accidental injury or the improvement of the
functioning of a malformed body member are covered. Some examples include:
• Surgery performed in connection with the treatment of severe burns;
• Surgery to repair the face following a serious automobile accident; and
• Surgery for therapeutic purposes that may coincidentally also serve some cosmetic purpose.
C) Items and Services Furnished by the Beneficiary’s Immediate Relatives and Members
of the Beneficiary’ s Household
Payment for items and services furnished by the beneficiary’s immediate relatives and members of
the beneficiary’s household will not be made since these items and services are ordinarily furnished
gratuitously because of the relationship between the beneficiary and the provider or supplier.
The following items and services will also not be paid:
• Charges for services furnished by a related physician or supplier that are submitted by an unrelated individual, partnership, or professional corporation; and
• Those services furnished incident to a physician’s professional service when the ordering or supervising physician has a prohibited relationship to the beneficiary.
A professional corporation is:
• Completely owned by one or more physicians or is owned by other health care professionals as authorized by State law; and
• Operated for the purpose of conducting the practice of medicine, osteopathy, dentistry,
podiatry, optometry, or chiropractic.
Any physician or group of physicians that is incorporated constitutes a professional corporation. Items and services furnished by non-physician suppliers that have a prohibited relationship with the beneficiary and are not incorporated will not be paid, regardless of whether the supplier is owned by a sole proprietor who is related to the beneficiary or owned by a partnership in which one of the partners is related to the beneficiary. This payment restriction applies only to professional corporations, regardless of the beneficiary’s relationship to any of the stockholders, officers, or directors of the corporation or to the individual who furnished the service.
A beneficiary’s immediate relatives include the following degrees of relationship:
• Husband and wife;
• Natural or adoptive parent, child, and sibling;
• Stepparent, stepchild, stepbrother, and stepsister;
• Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
• Grandparent and grandchild; and
• Spouse of grandparent or grandchild.
If the marriage upon which a step- or in-law relationship is based becomes terminated through
divorce or death, the prohibited relationship will continue to exist.
Members of the beneficiary’s household include the following who share a common abode with him
or her as part of a single family unit:
• Individuals who are related by blood, marriage, or adoption;
• Domestic employees; and
• Other individuals who live together as part of a single family unit (does not include roomers or boarders).
D) Dental Services
Items and services that are furnished in connection with the care, treatment, filling,removal, or replacement of teeth or the structures directly supporting the teeth are not covered. The structures that directly support the teeth are the periodontium, which includes:
• The gingivae;
• The dentogingival junction;
• The periodontal membrane;
• The cementum; and
• The alveolar process.
Whether or not the beneficiary is hospitalized has no direct bearing on if payment will be made for a
given dental procedure.
Some dental services may be covered depending upon whether the primary procedure that the
dentist performs is covered. For example, the following services are covered:
• An x-ray that is taken in connection with the reduction of a fracture of the jaw or facial bone; and
• A tooth extraction that is performed to prepare the jaw for radiation treatments of neoplastic disease.
I)Non-Physician Services Furnished to Hospital and Skilled Nursing Facility Inpatients That Are Not Provided Directly or Under Arrangement
In general, non-physician services furnished to Part A and Part B hospital inpatients and Part A
SNF inpatients that are not provided directly or under arrangement are not covered.
The following are covered:
• Physician services furnished to hospital and SNF inpatients (with the exception of therapy,
which must be provided by the SNF);
• Physician assistant services;
• Nurse practitioner services;
• Clinical nurse specialist services;
• Certified nurse-midwife services;
• Qualified clinical psychologist services; and
• Certified registered nurse anesthetist services.
The following Part A SNF inpatient services may be covered if they are not provided directly or under arrangement and are furnished by an authorized provider or supplier:
• 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);
• Hospice care related to a beneficiary’s terminal condition;
• Radioisotope services;
• Some customized prosthetic devices;
• Some chemotherapy and chemotherapy administration services; and
• The following services that are considered beyond the scope of a SNF when furnished in a participating hospital or Critical Access Hospital, including ambulance services related to such services (does not apply to services furnished in an Ambulatory Surgical Center):
◦ Cardiac catheterization;
◦ Computerized axial tomography scans;
◦ Magnetic resonance imaging;
◦ Ambulatory surgery that involves the use of an operating room;
◦ Radiation therapy; and
◦ Emergency services.
E) Certain Foot Care Services and Supportive Devices for the Feet
The following foot care services and devices are generally not covered, except as described below
• 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); and
◦ Orthopedic shoes and other supportive devices for the feet.
The following devices and services are covered:
• Orthopedic shoes that are an integral part of a leg brace;
• Therapeutic shoes furnished to diabetics;
• Services that are a necessary and integral part of an otherwise covered service (for example, the diagnosis and treatment of ulcers, wounds, or infections);
• Treatment of warts on the foot (including plantar warts);
• Treatment of mycotic nails as follows:
◦ For an ambulatory beneficiary, the physician attending the mycotic condition must document that:
▪ There is clinical evidence of mycosis of the toenail; and
▪ The beneficiary has marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
◦ 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; and
▪ The beneficiary suffers from pain or secondary infection resulting from the thickening and dystrophy of the infected toenail plate; and
• Presence of a systemic condition such as one of the following metabolic, neurologic, and peripheral vascular diseases (this is not an all-inclusive list):
◦ Diabetes mellitus;*
◦ Arteriosclerosis obliterans;
◦ Buerger’s disease;
◦ Chronic thrombophlebitis;* and
◦ Peripheral neuropathies that involve the feet:
▪ Associated with malnutrition and vitamin deficiency:*
▫ Malnutrition (general, pellagra);
▫ Malabsorption (celiac disease, tropical sprue); and
▫ 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; and
▪ Associated with hereditary disorders:
▫ Hereditary sensory radicular neuropathy;
▫ Angiokeratoma corporis diffusum (Fabry’s); and
▫ Amyloid neuropathy.
*For Medicare to cover routine procedures for this condition, the beneficiary must be under the active care of a MD or a DO who has documented the condition.
F) Investigational Devices
Category A devices, as categorized by the U.S. Food and Drug Administration, are considered
not medically reasonable and necessary and are therefore not covered.
Category B devices may be covered if they are considered medically reasonable and necessary
and all other applicable Medicare coverage requirements are met.
G) Services Related to and Required as a Result of Services That Are Not Covered
Medical and hospital services that are related to and required as a result of services that are not covered will not be paid. Some examples of these services are:
• Cosmetic surgery;
• Non-covered organ transplants; and
• Services related to follow-up care or complications that require treatment during a hospital stay in which a non-covered service is performed.
When a beneficiary is hospitalized for a non-covered service and requires services that are not related to the non-covered service, the unrelated services are covered. For example, if a beneficiary breaks a leg while he or she is in the hospital for a non-covered service, the services to treat the broken leg are covered since they are not related to the non-covered service.
When a beneficiary is discharged from a hospital stay in which he or she receives non-covered
services and subsequently requires services to treat a condition or complication that arose as a
result of the non-covered services, reasonable and necessary medical or hospital services may be
covered. Some examples include:
• Repair of complications after transsexual or cosmetic surgery; and
• Treatment of an infection at the surgical site of a non-covered service.
Any subsequent services that could be incorporated into a global fee are considered paid in the global fee and will not be paid again.