(Medicare Benefit Policy Manual)

Basic personal services such as simple barber and beautician services (e.g., shaves, haircuts, shampoos, and simple hair sets) whi ch patients need and cannot perform for themselves may be viewed as ordinary patient care when furnished by a long -stay institution.  Such services are covered costs reimbursable under Part A when included in the flat rate charge and provided routinely wit hout charge to the patient by an SNF or by a general psychiatric or tuberculosis hospital.  The services are maintenance of at least a minimum level of personal hygiene, decency, and presentability  items  essential to the well-being of the patient and of ot her patients who must associate with the patient.  However, under the personal comfort exclusion, more elaborate services, such as professional manicures, hair styling, etc., are excluded even when furnished routinely and without special charge.   90 - Routine Services and Appliances  (Rev. 186, Issued: 04- 16-14, Effective: 01- 01 01, Implementation: 05 -12-14)  Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye re fractions by whatever practitioner and for whatever purpose performed; hearing aids and examinations for hearing aids; and immunizations are not covered.   The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies.  The routine physical checkup exclusion does not appl y to the following services (as noted in section 42 CFR 411.15(a)(1)):    Screening mammography,   Colorectal cancer screening tests,   Screening pelvic exams,   Prostate cancer screening tests,   Glaucoma screening exams,   Ultrasound screening for abdomi nal aortic aneurysms (AAA),   cardiovascular disease screening tests,   diabetes screening tests,   screening electrocardiogram,   Initial preventive physical examinations,   Annual wellness visits providing personalized prevention plan services, and  Additional preventive services that meet the criteria specified in 42 CFR 410.64.  If the claim is for a diagnostic test or examination performed solely for the purpose of establishing a claim under title IV of Public Law 91 -173, Black Lung Benefits, the  service is not covered under Medicare and the claimant should be advised to contact their Social Security office regarding the filing of a claim for reimbursement under the Black Lung program.  The exclusions apply to eyeglasses or contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors.  The exclusions do not apply to physicians services (and services incident to a physicians service) performed in conjunction with an eye disease, as for example, glaucoma or cataracts, or to post -surgical prosthetic lenses which are customarily used during convalescence from eye surgery in which the lens of the eye was removed, or to permanent prosthetic lenses required by an individua l lacking the organic lens of the eye, whether by surgical removal or congenital disease.  Such prosthetic lens is a replacement for an internal body organ -  the lens of the eye.  (See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Ot her Health Services, 120).   Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage.   A.  Im munizations   Vaccinations or inoculations are excluded as immunizations unless they are either:    Directly related to the treatment of an injury or direct exposure to a disease or condition, such as antirabies treatment, tetanus antitoxin or booster vaccine , botulin antitoxin, antivenin sera, or immune globulin. (In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered.); or    Specifically cove red by statute, as described in the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50 .4.4.2.  B.  Antigens   Prior to the Omnibus Reconciliation Act of 1980, a physician who prepared an antigen for a patient could not be reimbursed for that service unless the physician also administered the antigen to the patient.  Effective January 1, 1981, payment may be made for a reasonable supply of antigens that have been prepared for a particular patient even though they have  not been administered to the patient by the same physician who prepared them if:    The antigens are prepared by a physician who is a doctor of medicine or osteopathy, and   The physician who prepared the antigens has examined the patient and has determined  a plan of treatment and a dosage regimen.  A reasonable supply of antigens is considered to be not more than a 12 -month supply of antigens that has been prepared for a particular patient at any one time.  The purpose of the reasonable supply limitation is  to assure that the antigens retain their potency and effectiveness over the period in which they are to be administered to the patient.  (See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50.4.4.1 )  100 - Hearing Aids and Auditory Implants  (Rev. 39; Issued: 11- 10-05; Effective: 11- 10-05; Implementation:  12 -12-05)  Section 1862(a)(7)  of the Social Security Act states that no payment may be made under part A or part B for any expenses incurred for items or services where such expenses are for . . . hearing aids or examinations therefore. . . .  This policy is further reiterated at  42 CFR 411.15(d)  which specifically states that hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids are excluded f rom coverage.   Hearing aids are amplifying devices that compensate for impaired hearing.  Hearing aids include air conduction devices that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound.  They also incl ude bone conduction devices that provide mechanical energy to the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.   Certain devices that produce perception of s ound by replacing the function of the middle ear, cochlea or auditory nerve are payable by Medicare as prosthetic devices.  These devices are indicated only when hearing aids are medically inappropriate or cannot be utilized due to congenital malformations , chronic disease, severe sensorineural hearing loss or surgery.  The following are prosthetic devices:    Cochlear implants and auditory brainstem implants, i.e., devices that replace the function of cochlear structures or auditory nerve and provide electri cal energy to auditory nerve fibers and other neural tissue via implanted electrode arrays.    Osseointegrated implants, i.e., devices implanted in the skull that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer.  Medicare contractors deny payment for an item or service that is associated with any hearing aid as defined above.  See 180 for policy for the medically necessary treatment of complications of implantable hearin g aids, such as medically necessary removals of implantable hearing aids due to infection.   110 - Custodial Care  (Rev. 1, 10- 01-03) A3-3159, HO -260.10, HO -261, B3 -2326   Custodial care is excluded from coverage.  Custodial care serves to assist an individua l in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be self -administered.  Custodial c are essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel.  In determining whether a person is receiving custodial care, the A/B MAC (A) or (B) considers the level of care and medical supervision required and furnished.  It does not base the decision on diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.   Institutional care that is below the level of care covered in a SNF is custodial care. (See the Med icare 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 an d 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 patients 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 patients 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 M anual, 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 accidental injury or for the improvement of the functioning of a malformed body member.  For example, thi s exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose.  130 - Charges Imposed by Immediate Relatives of the Patient or Members of the Patients Household  (Rev. 1, 10- 01-03) A3-3161, HO -260.12, B3- 2332  A.  General  These are expenses that constitute charges by immediate relatives of the beneficiary or by members of their household.  The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge.  This exclusion applies to items an d services rendered by providers to immediate relatives of the owner(s) of the provider.  It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplie r.  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.