Routine Services and Appliances

90 - Routine Services and Appliances (Rev. 186, Issued: 04-16-14, Effective: 01-01 01, Implementation: 05-12-14) Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye refractions by whatever practitioner and for whatever purpose performed; hearing aids and examinations for hearing aids; and immunizations are not covered. The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies. The routine physical checkup exclusion does not apply to the following services (as noted in section 42 CFR 411.15(a)(1)): • Screening mammography, • Colorectal cancer screening tests, • Screening pelvic exams, • Prostate cancer screening tests, • Glaucoma screening exams, • Ultrasound screening for abdominal aortic aneurysms (AAA), • cardiovascular disease screening tests, • diabetes screening tests, • screening electrocardiogram, • Initial preventive physical examinations, • Annual wellness visits providing personalized prevention plan services, and • Additional preventive services that meet the criteria specified in 42 CFR 410.64. If the claim is for a diagnostic test or examination performed solely for the purpose of establishing a claim under title IV of Public Law 91-173, “Black Lung Benefits,” the service is not covered under Medicare and the claimant should be advised to contact their Social Security office regarding the filing of a claim for reimbursement under the “Black Lung” program. The exclusions apply to eyeglasses or contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors. The exclusions do not apply to physicians’ services (and services incident to a physicians’ service) performed in conjunction with an eye disease, as for example, glaucoma or cataracts, or to post-surgical prosthetic lenses which are customarily used during convalescence from eye surgery in which the lens of the eye was removed, or to permanent prosthetic lenses required by an individual lacking the organic lens of the eye, whether by surgical removal or congenital disease. Such prosthetic lens is a replacement for an internal body organ - the lens of the eye. (See the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §120). Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage. A. Immunizations Vaccinations or inoculations are excluded as immunizations unless they are either: • Directly related to the treatment of an injury or direct exposure to a disease or condition, such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. (In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered.); or • Specifically covered by statute, as described in the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §50.4.4.2. B. Antigens Prior to the Omnibus Reconciliation Act of 1980, a physician who prepared an antigen for a patient could not be reimbursed for that service unless the physician also administered the antigen to the patient. Effective January 1, 1981, payment may be made for a reasonable supply of antigens that have been prepared for a particular patient even though they have not been administered to the patient by the same physician who prepared them if: • The antigens are prepared by a physician who is a doctor of medicine or osteopathy, and • The physician who prepared the antigens has examined the patient and has determined a plan of treatment and a dosage regimen. A reasonable supply of antigens is considered to be not more than a 12-month supply of antigens that has been prepared for a particular patient at any one time. The purpose of the reasonable supply limitation is to assure that the antigens retain their potency and effectiveness over the period in which they are to be administered to the patient. (See the Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services,” §50.4.4.1)