General Exclusions from Coverage

10 - General Exclusions from Coverage (Rev. 198, Issued: 11-06-14, Effective: 01-01-15, Implementation: 01-05-15) No payment can be made under either the hospital insurance or supplementary medical insurance program for certain items and services, when the following conditions exist: • Not reasonable and necessary (§20); • No legal obligation to pay for or provide (§40); • Paid for by a governmental entity (§50); • Not provided within United States (§60); • Resulting from war (§70); • Personal comfort (§80); • Routine services and appliances (§90); • Custodial care (§110); • Cosmetic surgery (§120); • Charges by immediate relatives or members of household (§130); • Dental services (§140); • Paid or expected to be paid under workers’ compensation (§150); • Non-physician services provided to a hospital inpatient that were not provided directly or arranged for by the hospital (§170); • Services Related to and Required as a Result of Services Which are not Covered Under Medicare (§180); • Excluded foot care services and supportive devices for feet (§30); or, • Excluded investigational devices (See Chapter 14).