Page 12 - Medicare Benefit Policy Manual

Reasonable and necessary services associated with treatment for infertility are covered
under Medicare. Infertility is a condition sufficiently at variance with the usual state of
health to make it appropriate for a person who normally is expected to be fertile to seek
medical consultation and treatment.

20.2 - Physician Expense for Allergy Treatment

(Rev. 1, 10-01-03)
B3-2005.2, B3-4145

Allergists commonly bill separately for the initial diagnostic workup and for the
treatment (See §60.2). Where it is necessary to provide treatment over an extended
period, the allergist may submit a single bill for all of the treatments, or may bill
periodically. In either case the Form CMS-1500 claim shows the Healthcare Common
Procedure Coding System (HCPCS) codes and from and through dates of service, or the
Form CMS-1450 outpatient claim shows the HCPCS code and date of service (except for
critical access hospital (CAH) claims).

20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered
But Not Furnished
(Rev. 1, 10-01-03)
B3-2005.3

A. Date of Incurred Expense

If a custom-made item was ordered but not furnished to a beneficiary because the
individual died or because the order was canceled by the beneficiary or because the
beneficiary’s condition changed and the item was no longer reasonable and necessary or
appropriate, payment can be made based on the supplier’s expenses. (See subsection B
for determination of the allowed amount.) In such cases, the expense is considered
incurred on the date the beneficiary died or the date the supplier learned of the
cancellation or that the item was no longer reasonable and necessary or appropriate for
the beneficiary’s condition. If the beneficiary died or the beneficiary’s condition changed
and the item was no longer reasonable and necessary or appropriate, payment can be
made on either an assigned or unassigned claim. If the beneficiary, for any other reason,
canceled the order, payment can be made to the supplier only.

B. Determination of Allowed Amount

The allowed amount is based on the services furnished and materials used, up to the date
the supplier learned of the beneficiary’s death or of the cancellation of the order or that
the item was no longer reasonable and necessary or appropriate. The A/B MAC (B) or
(HHH), or DME MAC as appropriate, determines the services performed and the
allowable amount appropriate in the particular situation. It takes into account any salvage
value of the device to the supplier.