Page 29 - Medicare Benefit Policy Manual

Institutional care that is below the level of care covered in a SNF is custodial care. (See
the Medicare Benefit Policy Manual, Chapter 8, “Coverage of Extended Care (SNF)
Services Under Hospital Insurance,” §30.) Some examples of custodial care in hospitals
and SNFs are:

• A stroke patient who is ambulatory, has no bladder or bowel involvement, no
serious associated or secondary illnesses and does not require medical or
paramedical care but requires only the assistance of an aide in feeding, dressing,
and bathing;

• A cardiac patient who is stable and compensated and has reasonable cardiac
reserve and no associated illnesses, but who because of advanced age has
difficulty in managing alone in the home, and requires assistance in meeting the
activities of daily living; and

• A senile patient who has diabetes which remains stabilized as long as someone
sees to it that the patient takes oral medication and sticks to a prescribed diet.

Even if a patient’s stay in a hospital or SNF is determined to be custodial, some
individual services may still be covered under Part B if they are reasonable and
necessary. For example, periodic visits by a physician to their patient are covered under
Part B if such services are reasonable and necessary to the treatment of the patient’s
illness or injury even though a finding has been made that the care being furnished the
patient in the hospital or SNF is custodial care and, therefore, not covered. Similarly,
such a finding of custodial care does not preclude payment for a Part B claim for
ancillary services, which are medically necessary (see the Medicare Benefit Policy
Manual, Chapter 15, “Covered Medical and Other Health Services,” §250). (See the
Medicare Benefit Policy Manual, Chapter 6, “Hospital Services Covered Under Part B,”
§10, and Chapter 8, §80.)

110.1 - Custodial Care Under a Hospice Program
(Rev. 1, 10-01-03)
A3-3159.1

Care furnished to an individual who has elected the hospice care option is custodial only
if it is not reasonable and necessary for the palliation or management of the terminal
illness or related conditions. (See the Medicare Benefit Policy Manual, Chapter 9,
“Coverage of Hospice Services Under Hospital Insurance,” §40.)

120 - Cosmetic Surgery
(Rev. 1, 10-01-03)
A3-3160, HO-260.11, B3-2329

Cosmetic surgery or expenses incurred in connection with such surgery is not covered.
Cosmetic surgery includes any surgical procedure directed at improving appearance,
except when required for the prompt (i.e., as soon as medically feasible) repair of