Page 27 - Medicare Benefit Policy Manual

Expenses for all refractive procedures, whether performed by an ophthalmologist (or any
other physician) or an optometrist and without regard to the reason for performance of the
refraction, are excluded from coverage.

A. Immunizations

Vaccinations or inoculations are excluded as immunizations unless they are either:

• Directly related to the treatment of an injury or direct exposure to a disease or
condition, such as antirabies treatment, tetanus antitoxin or booster vaccine,
botulin antitoxin, antivenin sera, or immune globulin. (In the absence of injury or
direct exposure, preventive immunization (vaccination or inoculation) against
such diseases as smallpox, polio, diphtheria, etc., is not covered.); or

• Specifically covered by statute, as described in the Medicare Benefit Policy
Manual, Chapter 15, “Covered Medical and Other Health Services,” §50.4.4.2.

B. Antigens

Prior to the Omnibus Reconciliation Act of 1980, a physician who prepared an antigen
for a patient could not be reimbursed for that service unless the physician also
administered the antigen to the patient. Effective January 1, 1981, payment may be made
for a reasonable supply of antigens that have been prepared for a particular patient even
though they have not been administered to the patient by the same physician who
prepared them if:

• The antigens are prepared by a physician who is a doctor of medicine or
osteopathy, and

• The physician who prepared the antigens has examined the patient and has
determined a plan of treatment and a dosage regimen.

A reasonable supply of antigens is considered to be not more than a 12-month supply of
antigens that has been prepared for a particular patient at any one time. The purpose of
the reasonable supply limitation is to assure that the antigens retain their potency and
effectiveness over the period in which they are to be administered to the patient. (See the
Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health
Services,” §50.4.4.1)

100 - Hearing Aids and Auditory Implants
(Rev. 39; Issued: 11-10-05; Effective: 11-10-05; Implementation: 12-12-05)

Section 1862(a)(7) of the Social Security Act states that no payment may be made under
part A or part B for any expenses incurred for items or services “where such expenses are
for . . . hearing aids or examinations therefore. . . .” This policy is further reiterated at