Tests that Require ABNs:
Medicare will not pay for the following:
• Routine physicals and most tests for screening,
• Most shots (vaccinations).
• Routine eye care, eyeglasses and examinations.
• Hearing aids and hearing examinations.
• Cosmetic surgery.
• Most outpatient prescription drugs.
• Dental care and dentures (in most cases).
• Orthopedic shoes and foot supports (orthotics).
• Routine foot care and flat foot care.
• Health care received outside of the USA.
• Services by immediate relatives.
• Services required as a result of war.
• Services under a physician's private contract.
• Services paid for by a governmental entity that is not Medicare.
• Services for which the patient has no legal obligation to pay.
• Home health services furnished under a plan of care, if the agency does not submit the claim.
• Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997.
|• Items or services
furnished in a competitive acquisition area by any entity that does not
have a contract with the Department of Health and Human Services (except
in a case of urgent need).
• Physicians' services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless they are furnished under arrangements by the hospital.
• Items and services furnished to an individual who is a resident of a skilled nursing facility (a SNF) or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF.
• Services of an assistant at surgery without prior approval from the peer review organization.
• Outpatient occupational and physical therapy services furnished incident to a physician's services.
is only a general summary of exclusions from Medicare benefits. It is not
a legal document. The official Medicare program provisions are contained
in relevant laws, regulations, and rulings.
General Information re: ABNs
• Part B of title XVIII of the Social Security Act (the Act) provides for Supplementary Medical Insurance (SMI) for certain Medicare beneficiaries, specifying what health care items or services the Medicare Part B program will cover.
• Diagnostic laboratory tests are generally covered under Part B, unless excluded from coverage by the Act. Services that are generally excluded from coverage include routine physical examinations and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury.
• CMS interprets these provisions to prohibit coverage of screening services, including laboratory tests furnished in the absence of signs, symptoms, or personal history of disease or injury, except as explicitly authorized by statute. A test may be considered medically appropriate, but nonetheless be excluded from Medicare coverage by statute.
• A national coverage policy for diagnostic laboratory test(s) is a document stating CMS's policy with respect to the circumstances under which the test(s) will be considered reasonable and necessary, and not screening, for Medicare purposes. Such a policy applies nationwide.
• A national coverage policy is neither a practice parameter nor a statement of the accepted standard of medical practice. Words such as "may be indicated" or "may be considered medically necessary" are used for this reason. Where a policy gives a general description and then lists examples (following words like "for example" or "including'), the list of examples is not meant to be all-inclusive but merely to provide some guidance.