An Advance Beneficiary Notice (ABN) is
a written notice which a physician or supplier give to a Medicare
beneficiary. The purpose of the ABN is to inform a beneficiary before
he or she receive specified items or services that other wise might
be paid for by Medicare that Medicare probably will not pay for them
for that particular beneficiary on that particular occasion. The ABN
allows the beneficiary to make an informed consumer decision whether
or not to receive the items or services for which he or she may have
to pay out of pocket or through other insurance.
Tests that Require ABNs:
• AIpha-feto protein
• Blood Counts
• Blood Glucose Testing
• Carcinoembryonic Antigen
• Collagen Crosslinks, Any Method
• Digoxin Therapeutic Drug Assay
• Fecal Occult Blood Test
• Gamma Glutamyl Transferase
• Glycated Hemoglobin/Glycated Protein
• Hepatitis Panel/Acute Hepatitis Panel
• Human Chorionic Gonadotropin
• Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
• Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)
• Lipids Testing
• Partial Thromboplastin Time (PTT)
• Prostate Specific Antigen
• Prothrombin Time (PT)
• Serum Iron n Studies
• Thyroid Testing
• Tumor Antigen by Immunoassay - CA 12
• Tumor Antigen by Immunoassay CA 15-3/CA 27.29
• Tumor Antigen by Immunoassay CA 19-9
• Urine Culture, Bacterial
Medicare will not pay for the following:
1. Because it does not meet the definition of any Medicare benefit.
2. Because of the following exclusion from Medicare benefits:
• 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.
• 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.
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.