Page 35 - Medicare Benefit Policy Manual

and complications of non-covered services which require treatment during a hospital stay
in which the non-covered service was performed, are not covered services under
Medicare. Services "not related to" non-covered services are covered under Medicare.

Following are examples of services "related to" and "not related to" non-covered services
while the beneficiary is an inpatient:

• A beneficiary was hospitalized for a non-covered service and broke a leg while in
the hospital. Services related to care of the broken leg during this stay is a clear
example of "not related to" services and are covered under Medicare.

• A beneficiary was admitted to the hospital for covered services, but during the
course of hospitalization became a candidate for a non-covered transplant or
implant and actually received the transplant or implant during that hospital stay.
When the original admission was entirely unrelated to the diagnosis that led to a
recommendation for a non-covered transplant or implant, the services related to
the admitting condition would be covered.

• A beneficiary was admitted to the hospital for covered services related to a
condition which ultimately led to identification of a need for transplant and
receipt of a transplant during the same hospital stay. If, on the basis of the nature
of the services and a comparison of the date they are received with the date on
which the beneficiary is identified as a transplant candidate, the services could
reasonably be attributed to preparation for the non-covered transplant, the services
would be "related to" non-covered services and would also be non-covered.

Following is an example of services received subsequent to a non-covered inpatient stay:

After a beneficiary has been discharged from the hospital stay in which the beneficiary
received non-covered services, medical and hospital services required to treat a condition
or complication that arises as a result of the prior non-covered services may be covered
when they are reasonable and necessary in all other respects. Thus, coverage could be
provided for subsequent inpatient stays or outpatient treatment ordinarily covered by
Medicare, even if the need for treatment arose because of a previous non-covered
procedure. Some examples of services that may be found to be covered under this policy
are the reversal of intestinal bypass surgery for obesity, complications from cosmetic
surgery, removal of a non-covered bladder stimulator, or treatment of any infection at the
surgical site of a non-covered transplant that occurred following discharge from the
hospital.

However, any subsequent services that could be expected to have been incorporated into
a global fee are not covered. Thus, where a patient undergoes cosmetic surgery and the
treatment regimen calls for a series of postoperative visits to the surgeon for evaluating
the patient's progress, these visits are not covered.