Page 9 - Medicare Benefit Policy Manual

10 - Supplementary Medical Insurance (SMI) Provisions
(Rev. 37, Issued: 08-12-05; Effective/Implementation: 09-12-05)

The supplementary medical insurance plan covers expenses incurred for the following
medical and other health services under Part B of Medicare:

• Physician’s services, including surgery, consultation, office and institutional
calls, and services and supplies furnished incident to a physician’s professional
service;

• Outpatient hospital services furnished incident to physicians services;

• Outpatient diagnostic services furnished by a hospital;

• Outpatient physical therapy, outpatient occupational therapy, outpatient speech-
language pathology services;

• Diagnostic x-ray tests, laboratory tests, and other diagnostic tests;

• X-ray, radium, and radioactive isotope therapy;

• Surgical dressings, and splints, casts, and other devices used for reduction of
fractures and dislocations;

• Rental or purchase of durable medical equipment for use in the patient’s home;

• Ambulance service;

• Prosthetic devices, other than dental, which replace all or part of an internal body
organ;

• Leg, arm, back and neck braces and artificial legs, arms, and eyes including
adjustments, repairs, and replacements required because of breakage, wear, loss,
or change in the patient’s physical condition;

• Certain medical supplies used in connection with home dialysis delivery systems;

• Rural health clinic (RHC) services;

• Federally Qualified Health Center (FQHC) services;

• Ambulatory surgical center (ASC) services;

• Screening mammography services;

• Screening pap smears and pelvic exams;