(Medicare Benefit Policy Manual)

B.  Immediate Relative   The following degrees of relationship are included within the definition of immediate relative.    Husband and wife;    Natural or adoptive parent, child, and sibling;    Stepparent, stepchild, stepbrother, and stepsister;    Father -in-law, mother -in-law, son- in-law, daughter -in-law, brother -in-law, and sister -in-law;   Grandparent and grandchild; and    Spouse of grandparent and grandchild.   NOTE 1:   A brother -in-law or sister -in-law relationship does not exist between the physician, supplier or owner of a provider (or supplier) and the spouse of his wifes or her husbands brother or sister.  NOTE 2:   A father -in-law or mother -in-law relationship does not exist between a physician or the owner of a provider and his or her spouses stepfat her or stepmother.   A step -relationship and an in- law relationship continues to exist even if the marriage upon which the relationship is based is terminated through divorce or through the death of one of the parties.  For example, if a provider treats the  stepfather of the owner after the death of the owners natural mother or after the owners stepfather and natural mother are divorced, or if the provider treats the owners father -in-law or mother -in-law after the death of their spouse, the services are c onsidered to have been furnished to an immediate relative, and therefore, are excluded from coverage.   C.  Members of Patients Household   These are persons sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit.  A mere roomer or boarder is not included.  D.  Charges for Provider Services  Payment is not made under Part A or Part B for items and services  furnished by providers to immediate relatives of the owner(s) of the providers.  This exclusion applies whether the provider is a sole proprietor who has an excluded relationship to the patient, or a partnership in which even one of the partners is relate d to the patient.  E.  Charges for Physician and Physician -Related Services   This exclusion applies to physician services, including services of a physician who belongs to a professional corporation, and services furnished incident to those services (for e xample, by the physicians nurse or technician) if the physician who furnished the services or who ordered or supervised services incident to their services has an excluded relationship to the beneficiary.   Professional corporation means a corporation that  is completely owed by one or more physicians, and is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by State law.  Any physician or group of physicians which is incorporated constitutes a professional corporation. (Generally, physicians who are incorporated identify themselves by adding letters such as P.C. or P.A. after their title.)   F.  Charges for Items Furnished b y Nonphysician Suppliers   This exclusion applies to charges imposed by a nonphysician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who has an excluded relationship to the patient, or by a partnership in which even one of the partners is related.  It does not apply to charges imposed by a corporation (other than a professional corporation), regardless of the patients relationship to any of the stockholders, officers, or directors of the corporation or to the person w ho furnished the service.   140 - Dental Services Exclusion  (Rev. 1, 10- 01-03) A3-3162, HO -260.13, B3- 2336  Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are  not covered.  Structures directly supporting the teeth mean the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum, and alveolar process.  However, payment may be made for certain other services of a dentist.  (See the Medicare Benefit Policy Manual, Chapter 15,  Covered Medical and Other Health Services , 150.)   The hospitalization or nonhospitalization of a patient has no direct bearing on the coverage or exclusion of a given dental procedure.   When an exclu ded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty.  For example, the extraction of an impacted tooth is not covered.  Similarly, an alveoplasty (the surgical improvement of the shape and condition of the alveolar process) and a frenectomy are excluded from coverage when either of these procedures is performed in connection with an excluded service, e.g., the preparation of the mouth for dentures.  In like manner, the removal of the torus palatinus (a bony protuberance of the hard palate) could be a covered service.  However, with rare exception, this surgery is performed in connection with an excluded service, i.e., the preparation of the mouth for dentures.  Under such circumstances, reimbursement is  not made for this purpose.   The extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease is also covered.  This is an exception to the requirement that to be covered, a noncovered procedure or service performed by a dentist must be an incident to and an integral part of a covered procedure or service performed by the dentist.  Ordinarily, the dentist extracts the patients teeth, but another physician, e.g., a radiologist, administers the radiation treatments.   Whether such s ervices as the administration of anesthesia, diagnostic x -rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is covered.  Thus, an x -ray taken in connection with the reduction of a fract ure of the jaw or facial bone is covered.  However, a single x -ray or x -ray survey taken in connection with the care or treatment of teeth or the periodontium is not covered.   See also the Medicare Benefit Policy Manual, Chapter 1,  Inpatient Hospital Serv ices, 70, and Chapter 15, Covered Medical and Other Health Services, 150 for additional information on dental services.  150 - Services Reimbursable Under Automobile, No Fault, Any Liability Insurance or Workers Compensation  (Rev. 1, 10- 01-03) A3-313, HO- 260.14, B3- 2370  The program may not pay for items and services for which payment has been made or can reasonably be expected to be made promptly under a liability, automobile, no- fault or workers compensation law or plan of the United States or a St ate. Also, payments for items and services under the health insurance program are subject to repayment to the appropriate trust fund if notice or information is received that payment is available for the items and services under a liability, automobile, no- fault or workers compensation plan.  See the MSP manual for specific instructions.   170 - Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider  (Rev. 1, 10- 01-03) A3-3164, HO -260.15, B3- 2390, PM A 00- 88  Nonphysic ian services provided to a Part A inpatient or Part B inpatient of a hospital or to a Part A inpatient of a SNF which are not provided directly by the hospital/SNF or under arrangement generally are excluded from coverage under Medicare.   This coverage exclusion does not apply to the following types of services:    Physicians services for hospital inpatients or physicians services other than therapy for SNF inpatients (i.e., therapy provided by physicians is not covered for any SNF Part A and Part B inpatient unless provided by the SNF, but other physician services may be covered.  Any normally -covered service may be provided by a physician to a hospital inpatient);    Physician assistant services;    Nurse practitioners and clinical nurse specialists;   Certified nurse -midwife services;    Qualified clinical psychologist services;    Certified registered nurse anesthetist; and    Services of an anesthetist employed by a physician that were furnished during cost reporting periods beginning on or after October 1, 1984, through any part of a cost reporting period occurring before January 1, 1989.  The A/B MAC (B)  may make direct payment on Part B bills for these services, if they are medically necessary, even though they are not furnished directly or arranged for b y the hospital/SNF.   For SNF Part A inpatients, the following services are additional exceptions to this non coverage rule and may be covered if provided by another authorized provider or supplier:    Home dialysis supplies and equipment, self -care home dial ysis support services, and institutional dialysis services and supplies, including any related necessary ambulance services;    EPO;    Hospice care related to a beneficiarys terminal condition;    Radioisotope services;    Some customized prosthetic devices;    Some chemotherapy and chemotherapy administration services;    The following services which are considered beyond the scope of a SNF when furnished in a  Medicare participating Hospital or Critical Access Hospital.  Note that this exception does not apply if the service is furnished in an ASC.  Specific coding is described in the Medicare Claims Processing Manual.    Cardiac catheterization;    CT scans;    MRIs;    Ambulatory surgery involving the use of an operating room;    Radiation therapy;    Emergency services;    Ambulance services related to the six services listed immediately above; and ambulance transportation related to dialysis services.   180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare  (Rev. 189, Issued: 06- 27-14, Effective: 05- 30-14, Implementation: 06- 29-14)  Medical and hospital services are sometimes required to treat a condition that arises as a result of services that are not covered because they are determined to be not reasonable and necessary or becau se they are excluded from coverage for other reasons.  Services "related to" non -covered services (e.g., cosmetic surgery, non -covered organ transplants, non-covered artificial organ implants, etc.), including services related to follow -up care and complic ations 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 ar e 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 service s 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 serv ices, 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 s ubsequent 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 fo r evaluating the patient's progress, these visits are not covered.