Coverage Determinations

3.6.2.1 - Coverage Determinations (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) The MACs, CERT, Recovery Auditors, and UPICs shall deny an item or service if it does not meet any of the conditions listed below: • The item or service does not fall into a Medicare benefit category. • The item or service is statutorily excluded on grounds other than §1862(a) (1) (A) of the Act. • The item or service is not reasonable and necessary under §1862(a) (1) (A) of the Act. • The item or service does not meet other Medicare program requirements for payment.