ABN Uses

50.2 - ABN Uses (Rev. 10862; Issued: 07-14-21; Effective: 10-14-21; Implementation: 10-14-21) The following provisions necessitate delivery of the ABN: • §1862(a)(1) of the Act (not reasonable and necessary); • §1834(a)(17)(B) of the Act (violation of the prohibition on unsolicited telephone contacts); • §1834(j)(1) of the Act (medical equipment and supplies supplier number requirements not met); • §1834(a)(15) of the Act (medical equipment and/or supplies denied in advance); • §1862(a)(9) of the Act (custodial care); • §1879(g)(2) of the Act (hospice patient who is not terminally ill); • §1879(g)(1) of the Act (home health services requirements are not met – not confined to the home or no need for intermittent skilled nursing care); • §1862(a)(1)(P) of the Act, Medicare covered personalized prevention plan services (as defined in §1861(hhh)(1)) that are performed more frequently than indicated per coverage guidelines are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member); • Under 42 CFR §414.408(e)(3)(ii) when a noncontract supplier furnishes an item included in the Durable Medical Equipment, Prosthetic, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) for a Competitive Bidding Area (CBA). Although all other denial reasons triggering mandatory use of the ABN are found in §1879 of the Act, in this situation, §1847(b)(5)(D) of the Act permits use of the ABN with respect to these items and services; or • When Medicare considers an item or service experimental (e.g., a “Research Use Only” or “Investigational Use Only” laboratory test), payment for the experimental item or service is denied under §1862(a)(1) of the Act as not reasonable and necessary. In circumstances such as this, the beneficiary must be given an ABN.