Page 3 - Medicare Benefit Policy Manual

10 - General Exclusions from Coverage
(Rev. 198, Issued: 11-06-14, Effective: 01-01-15, Implementation: 01-05-15)

No payment can be made under either the hospital insurance or supplementary medical
insurance program for certain items and services, when the following conditions exist:

• Not reasonable and necessary (§20);

• No legal obligation to pay for or provide (§40);

• Paid for by a governmental entity (§50);

• Not provided within United States (§60);

• Resulting from war (§70);

• Personal comfort (§80);

• Routine services and appliances (§90);

• Custodial care (§110);

• Cosmetic surgery (§120);

• Charges by immediate relatives or members of household (§130);

• Dental services (§140);

• Paid or expected to be paid under workers’ compensation (§150);

• Non-physician services provided to a hospital inpatient that were not provided
directly or arranged for by the hospital (§170);

• Services Related to and Required as a Result of Services Which are not Covered
Under Medicare (§180);

• Excluded foot care services and supportive devices for feet (§30); or,

• Excluded investigational devices (See Chapter 14).

20 - Services Not Reasonable and Necessary
(Rev. 1, 10-01-03)
A3-3151, HO-260.1, B3-2303, AB-00-52 - 6/00

Items and services which are not reasonable and necessary for the diagnosis or treatment
of illness or injury or to improve the functioning of a malformed body member are not
covered, e.g., payment cannot be made for the rental of a special hospital bed to be used