(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 15  Covered Medical and Other Health Services   Table of Contents  (Rev.  12448; Issued:  01-11-24)  Transmittals for Chapter 15  10 - Supplementary Medical Insurance (SMI) Provisions 20 - When Part B Expenses Are Incurred  20.1 - Physician Expense for Surgery, Childbirth, and Treatment for Infertility  20.2 - Physician Expense for Allergy Treatment  20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished  30 - Physician Services  30.1 - Provider- Based Physician Services  30.2 - Teaching Physician Services  30.3 - Interns and Residents  30.4 - Optometrists Services  30.5 - Chiropractors Services  30.6 - Indian Health Service (IHS) Physician and Nonphysician Services  30.6.1 - Payment for Medicare Part B Services Furnished by Certain IHS Hospitals and Clinics  40 - Effect of Beneficiary Agreements Not to Use Medicare Coverage  40.1 - Private Contracts Between Beneficiaries and Physicians/Practitioners  40.2 - General Rules of Private Contracts  40.3 - Effective Date of the Opt -Out Provision 40.4 - Definition of Physician/Practitioner  40.5 - When a Physician or Practitioner Opts Out of Medicare  40.6 - When Payment May be Made to a Beneficiary for Service of an Opt -Out Physician/Practitioner  40.7 - Definition of a Private Contract  40.8 - Requirements of a Private Contract  40.9 - Requirements of the Opt-Out Affidavit  40.10 - Failure to Properly Opt Out  40.11 - Failure to Maintain Opt- Out 40.12 - Actions to Take in Cases of Failure to Maintain Opt- Out 40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare  40.14 - Nonparticipating Physicians or Practitioners Who Opt Out of Medicare  40.15 - Excluded Physicians and Practitioners  40.16 - Relationship Between Opt- Out and Medicare Participation Agreements  40.17 - Participating Physicians and Practitioners  40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare  40.19 - Opt -Out Relationship to Noncovered Services  40.20 - Maintaining Information on Opt-Out Physicians  40.21 - Informing Medicare Managed Care Plans of the Identity of the Opt-Out Physicians or Practitioners  40.22 -  Informing the National Supplier Clearinghouse (NSC) of the Identity of the Opt -Out Physicians or Practitioners  40.23 -  Organizations That Furnish Physician or Practitioner Services  40.24 -  The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts  40.25 -  Private Contracting Rules When Medicare is the Secondary Payer  40.26 -  Registration and Identification of Physicians or Practitioners Who Opt Out  40.27 -  System Identification  40.28 -  Emergency and Urgent Care Situations  40.29 -  Definition of Emergency and Urgent Care Situations  40.30 -  Denial of Payment to Employers of Opt -Out Physicians and Practitioners  40.31 -  Denial of Payment to Beneficiaries and Others  40.32 -  Payment for Medically Necessary Services Ordered or Prescribed by an Opt -out physician or Practitioner  40.33 -  Mandatory Claims Submission  40.34 -  Cancellation of Opt -Out 40.35 -  Early Termination of Opt -Out 40.36 -  Appeals  40.37 -  Application to the Medicare Advantage Program  40.38 -  Claims Denial Notices to Opt- Out Physicians and Practitioners  40.39 -  Claims Denial Notices to Beneficiaries  50 - Drugs and Biologicals  50.1 -  Definition of Drug or Biological  50.2 -  Determining Self -Administration of Drug or Biological  50.3 -  Incident -to Requirements  50.4 -  Reasonableness and Necessity  50.4.1 -  Approved Use of Drug  50.4.2 -  Unlabeled Use of Drug  50.4.3 -  Examples of Not Reasonable and Necessary  50.4.4 -  Payment for Antigens and Immunizations  50.4.4.1 -  Antigens  50.4.4.2 -  Immunizations  50.4.5 -  Off Lable Use of Anti -Cancer Drugs and Biologicals  50.4.5.1 -  Process for Amending the List of Compendia for Determination of Medically -Accepted Indications for Off -Label Uses of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen  50.4.6 -  Less Than Effective Drug  50.4.7 -  Denial of Medicare Payment for Compounded Drugs Produced in Violation of Federal Food, Drug, and Cosmetic Act  50.4.8 -  Process for Amending the List of Compendia for Determination of Medically-Accepted Indications for Off -Label Uses of Drugs and Biologicals in an Anti -Cancer Chemotherapeutic Regimen  50.5 -  Self-Administered Drugs and Biologicals  50.5.1 -  Immunosuppressive Drugs  50.5.2 -  Erythropoietin (EPO)  50.5.2.1 -  Requirements for Medicare Coverage for EPO  50.5.2.2 -  Medicare Coverage of Epoetin Alfa (Procrit) for Preoperative Use  50.5.3 -  Oral Anti -Cancer Drugs  50.5.4 -  Oral Anti -Nausea (Anti -Emetic) Drugs  50.5.5 -  Hemophilia Clotting Factors  50.6 -  Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home  60 - Services and Supplies  Furnished Incident To a Physician's/NPP's Professional Service  60.1 -  Incident To Physicians Professional Services  60.2 -  Services of Nonphysician Personnel Furnished Incident To Physicians Services  60.3 -  Incident To PhysiciansServices in Clinic  60.4 -  Services Incident to a Physicians Service to Homebound Patients Under General Physician Supervision 60.4.1 -  Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit  70 - Sleep Disorder Clinics  80 - Requirements for Diagnostic X -Ray, Diagnostic Laboratory, and Other Diagnostic Tests  80.1 -  Clinical Laboratory Services  80.1.1 -  Certification Changes  80.1.2 -  A/B MAC (B)  Contacts With Independent Clinical Laboratories  80.1.3 -  Independent Laboratory Service to a Patient in the Patients Home or an Institution 80.2 -  Psychological and Neuropsychological Tests  80.3 -  Audiology Services  80.3.1 -  Definition of Qualified Audiologist  80.4 -  Coverage of Portable X -Ray Services Not Under the Direct Supervision of a Physician 80.4.1 -  Diagnostic X -Ray Tests  80.4.2 -  Applicability of Health and Safety Standards  80.4.3 -  Scope of Portable X -Ray Benefit  80.4.4 -  Exclusions From Coverage as Portable X -Ray Services  80.4.5 -  Electrocardiograms  80.5 -  Bone Mass Measurements (BMMs)  80.5.1 -  Background  80.5.2 -  Authority 80.5.3 -  Definition  80.5.4 -  Conditions for Coverage  80.5.5 -  Frequency Standards  80.5.6 -  Beneficiaries Who May be Covered  80.5.7 -  Noncovered BMMs  80.5.8 -  Claims Processing  80.5.9 -  National Coverage Determinations (NCDs)  80.6 -  Requirements for Ordering and Following Orders for Diagnostic Tests  80.6.1 -  Definitions  80.6.2 -  Interpreting Physician Determines a Different Diagnostic Test is Appropriate  80.6.3 -  Rules for Testing Facility to Furnish Additional Tests  80.6.4 -  Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests  80.6.5 -  Surgical/Cytopathology Exception 90 - X-Ray, Radium, and Radioactive Isotope Therapy  100 -  Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations  110 -  Durable Medical Equipment -  General  110.1 -  Definition of Durable Medical Equipment  110.2 -  Repairs, Maintenance, Replacement, and Delivery  110.3 -  Coverage of Supplies and Accessories  110.4 -  Miscellaneous Issues Included in the Coverage of Equipment  110.5 -  Incurred Expense Dates for Durable Medical Equipment  110.6 -  Determining Months for Which Periodic Payments May Be Made for Equipment Used in an Institution  110.7 -  No Payment for Purchased Equipment Delivered Outside the United States or Before Beneficiarys Coverage Began