(Medicare Claims Processing Manual)

20.1 - LOL Coverage Denials (Rev. 1, 10- 01-03) (Rev.:4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  A.  Statutory Basis   The following table provides examples of denials based on 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Act:   Statutory Provision  (section of the Act)  Description  1862(a)(1)(A)  Items and services found to be not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.  1862(a)(1)(B) & 1861(s)(10)  Pneumococcal vaccine and its administration, influenza vaccine and its administration, and hepatitis B vaccine and its administration furnished to an individual at high or intermediate risk of contracting hepatitis B, that are not reasonable and necessary for the prevention of illness.  1862(a)(1)(C)  In the case of hospice care, items and services that are not reasonable and necessary for the palliation or management of terminal illness.  Statutory Provision  (section of the Act)  Description  1862(a)(1)(E)  Items and services that, in the case of research conducted pursuant to 1142 of the Act, are not reasonable and necessary to carry out the purposes of that section (which concerns research on outcomes of health care services and procedures).  1862(a)(1)(F)  Screening mammography that is performed more frequently than is covered under 1834(c)(2) of the Act or that is not conducted by a facility described in 1834(c)(1)(B) of the Act and screening pap smears and screening pelvic exams performed more frequently than is provided for under 1861(nn) of the Act.  1862(a)(1)(F)  Screening for glaucoma, which is performed more frequently than is provided under 1861(uu) of the Act.  1862(a)(1)(G)  Prostate cancer screening tests (as defined in 1861(oo) of the Act), which are performed more frequently than is covered under such section.  1862(a)(1)(H)  Colorectal cancer screening tests, which are performed more frequently than is covered under 1834(d) of the Act.  1862(a)(1)(I)  The frequency and duration of home health services which are in excess of normative guidelines that the Secretary shall establish by regulation.  1862(a)(1)(J)  Drugs or biologicals specified in  1847A(c)(6)(C)  of the Act, for which payment is made under part B, furnished in a competitive area under  1847B  of the Act, but not furnished by an entity under a contract under 1847(B) of the Act.  1862(a)(1)(K)  An initial preventive physical examination, which is performed more than 1 year after the date the individuals first coverage period begins under Medicare Part B.  1862(a)(1)(L)  Cardiovascular screening blood tests (as defined in 1861(xx)(1)  of the Act), which are performed more frequently than is covered under  1861(xx)(2) . 1862(a)(1)(M)  A diabetes screening test (as defined in  1861(yy)(1)  of the Act), which is performed more frequently than is covered under  1861(yy)(3)  of the Act . 1862(a)(1)(N)  An ultrasound screening for abdominal aortic aneurysm which is performed more frequently than is provided for under 1861(s)(2)(AA)  of the Act.  1862(a)(1)(O)  Kidney disease education services (as defined in 1861(ggg)(1) of the Act) which are furnished in excess of the number of sessions covered under 1861(ggg)(4) of the Act.  1861(dd)(3)(A)  Hospice care determined to be non -covered because the beneficiary was not terminally ill, as referenced by 1879(g)(2) of the Act since the Balanced Budget Act of 1997.  1862(a)(1)(O)  Personalized prevention plan services (as defined in  1861 (hhh)(1) of the Act), which are performed more frequently than is covered under such section.  Statutory Provision  (section of the Act)  Description  1814(a)(2)(C) & 1835(a)(2)(A) on or after July 1, 1987   1879(g)(1) before December 31, 1995  Home health services determined to be non -covered because the beneficiary was not homebound or did not require intermittent skilled nursing care.  1879(e)  Inpatient hospital services or extended care services if payment is denied solely because of an unintentional, inadvertent, or erroneous action that resulted in the beneficiarys transfer from a certified bed (one that does not meet the requirements of 1861(e) or (j) of the Act) in a skilled nursing facility (SNF) or hospital.  1862(a)(9)  Custodial care, unless otherwise permitted under paragraph 1862(a)(1)(C) of the Act.      20.2 - Denials When the LOL Provision Does Not Apply   (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  Type of Denial  Description  Example(s)  Categorical  Categorical Denials are circumstances in which the LOL provision does not apply because the Medicare payment denial is based on a statutory provision not referenced in 1879 of the Act.  Refer to 1862(a)  of the Act for a complete listing.   Personal comfort items (1862(a)(6) of the Act).   Routine physicals and most screening tests (1862(a)(7) of the Act).    Most immunizations (vaccinations) (1862(a)(7) of the Act).   Routine eye care, most eyeglasses and examinations (1862(a)(7) of the Act).   Hearing aids and hearing aid examinations (1862(a)(7) of the Act).   Cosmetic surgery (1862(a)(10) of the Act).   Orthopedic shoes and foot supports (orthotics) (1862(a)(8) of the Act).   Type of Denial  Description  Example(s)  NOTE:   22.1 of this chapter provides a more expansive list of examples.  Technical  When coverage requirements are not met for a particular item or service, it is not a Medicare benefit; therefore, Medicare denies payment or when payment for a medically unreasonable or unnecessary item or service that is also barred because of failure to meet a condition of payment required by regulations.    Payment for the additional cost of a private room in a hospital or SNF is denied when the private accommodations are not required for medical reasons (1861(v)(2) of the Act).   Payment for a dressing is denied because it does not meet the definition for surgical dressings (1861(s)(5) of the Act).   Payment for SNF stays not preceded by the required 3 -day hospital stay or Payment for SNF stay because the beneficiary did not meet the requirement for transfer to a SNF and for receiving covered services within 30 days after discharge from the hospital and because the special requirements for extension of the 30 days were not met (1861(i) of the Act).   Drugs and biologicals which are usually self -administered by the patient.   Ambulance services denied because transportation by other means is not contraindicated or because regulatory criteria specified in 42 CFR 410.40, such as those relating to destination or nearest appropriate facility, are not met.  (See the Medicare Benefit Policy Manual, Chapter 10 )  Other items or services that must be denied under 42 CFR 410.12 through  410.105 of the Medicare regulations.    20.2.1 - Categorical Denials  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  Below is a more expansive list of examples of categorical denials:   Statutory Provision   (section  of the Act) Description  1862(a)(12)  Dental care and dentures (in most cases).  1862(a)(13)  Routine foot care and flat foot care.  1862(a)(19)  Services under a physicians private contract.  1862(a)(3)  Services paid for by a governmental entity that is not Medicare.  1862(a)(4)  Health care received outside of the U. S. not covered by Medicare.  1862(a)(11)  Services by immediate relatives.  1862(a)(5)  Services required as a result of war.  1862(a)(2)  Services for which there is no legal obligation to pay.  1862(a)(21)  Home health services furnished under a plan of care, if the agency does not submit the claim.  1862(a)(16)  Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997.  1862(a)(17)  Items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of Health and Human Services (except in a case of urgent need).  1862(a)(14)  Physicians services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless they are furnished under arrangement with the hospital.  1862(a)(18)  Items and services furnished to an individual who is a resident of a skilled nursing facility or of a part of a facility that includes a skilled nursing facility, unless they are furnished under arrangements by the skilled nursing facility.  1862(a)(15)  Services of an assistant at surgery without prior approval from the peer review organization.  1862(a)(20)  Outpatient occupational and physical therapy services furnished incident to a physicians services.  1862(a)(22)  Claims submitted other than in an electronic form specified by the Secretary, subject to the exceptions set forth in 1862(h) of the Act.  Statutory Provision   (section  of the Act) Description  1862(a)(23)  Claims for the technical component of advanced diagnostic imaging services described in 1834(e)(1)(B) of the Act for which payment is made under the fee schedule established under 1848(b) of the Act and that are furnished by a supplier (as defined in 1861(d) of the Act), if such supplier is not accredited by an accreditation organization designated by the Secretary under 1834(e)(2)(B) of the Act.  1862(a)(24)  Claims for renal dialysis services (as defined in 1881(b)(14)(B) of the Act) for which payment is made under such section unless such payment is made under such section to a provider of services or a renal dialysis facility for such services.    30 - Determining Liability for Disallowed Claims Under 1879  (Rev.: 4197; Issued: 01- 11-19; Effective: 04 -15-19; Implementation: 04 -15-19)  When a Medicare contractor determines that a review under the LOL provisions is appropriate under 20 of this chapter, the Medicare contractor must next determine who is liable, based on who knew, or should have known that Medicare was going to deny paymen t on the item or service.  In order to make this determination, the contractor must take the following steps:    NOTE:  If both the beneficiary and the healthcare provider or supplier are found to have knowledge, the beneficiary will be held liable.   Determine whether the beneficiary is liable.  Evidence must show that the beneficiary knew or should have known the item and/or service would not be covered.  Knowledge:  * Is established when the healthcare provider or supplier gives a valid ABN, Form CMS -R-131 or other written notice.  * May  be established when the beneficiary receives notice of a recent claim denial for the same item or service.