Page 26 - Medicare Benefit Policy Manual

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).