SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services

(1) An immediate relative of the beneficiary; or(2) A member of the beneficiary's household.(b)Definitions.As used in this sectionImmediate relativemeans any of the following:(1) Husband or wife.(2) Natural or adoptive parent, child, or sibling.(3) Stepparent, stepchild, stepbrother, or stepsister.(4) Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law.(5) Grandparent or grandchild.(6) Spouse of grandparent or grandchild.Member of the householdmeans any person sharing a common abode as part of a single family unit, including domestic employees and others who live together as part of a family unit, but not including a mere roomer or boarder.Professional corporationmeans a corporation that is completely owned 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.(c)Applicability of the exclusion.The exclusion applies to the following charges in the specified circumstances:(1)Physicians' services.(i) Charges for physicians' services furnished by an immediate relative of the beneficiary or member of the beneficiary's household, even if the bill or claim is submitted by another individual or by an entity such as a partnership or a professional corporation.(ii) Charges for services furnished incident to a physician's professional services (for example by the physician's nurse or technician), only if the physician who ordered or supervised the services has an excluded relationship to the beneficiary.(2)Services other than physicians' services.(i) Charges imposed by an individually owned provider or supplier if the owner has an excluded relationship to the beneficiary; and(ii) Charges imposed by a partnership if any of the partners has an excluded relationship to the beneficiary.(d)Exception to the exclusion.The exclusion does not apply to charges imposed by a corporation other than a professional corporation.AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.12 411.15 - Particular services excluded from coverage.The following services are excluded from coverage:(a) Routine physical checkups such as:(1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic exams, prostate cancer screening tests, glaucoma screening exams, ultrasound screening for abdominal aortic aneurysms (AAA), cardiovascular disease screening tests, diabetes screening tests, a screening electrocardiogram, initial preventive physical examinations that meet the criteria specified in paragraphs (k)(6) through (k)(15) of this section, additional preventive services that meet the criteria in  410.64 of this chapter, or annual wellness visits providing personalized prevention plan services.(2) Examinations required by insurance companies, business establishments, government agencies, or other third parties.(b)Low vision aid exclusion(1)Scope.The scope of the eyeglass exclusion encompasses all devices irrespective of their size, form, or technological features that use one or more lens to aid vision or provide magnification of images for impaired vision.(2)Exceptions.(i) Post-surgical prosthetic lenses customarily used during convalescence for eye surgery in which the lens of the eye was removed (for example, cataract surgery).(ii) Prosthetic intraocular lenses and one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.(iii) Prosthetic lenses used by Medicare beneficiaries who are lacking the natural lens of the eye and who were not furnished with an intraocular lens.(c)Eye examinationsfor the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only and procedures performed in the course of any eye examination to determine the refractive state of the eyes, without regard to the reason for the performance of the refractive procedures. Refractive procedures are excluded even when performed in connection with otherwise covered diagnosis or treatment of illness or injury.(d)Hearing aidsor examinations for the purpose of prescribing, fitting, or changing hearing aids.(1)Scope.The scope of the hearing aid exclusion encompasses all types of air conduction hearing aids that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound and bone conduction hearing aids that provide mechanical stimulation of the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.(2)Devices not subject to the hearing aid exclusion.Paragraph (d)(1) of this section shall not apply to the following devices that produce the perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve:(i) Osseointegrated implants in the skull bone that provide mechanical energy to the cochlea via a mechanical transducer, or(ii) Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays.(e)Immunizations, except for(1) Vaccinations or inoculations directly related to the treatment of an injury or direct exposure such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenom sera, or immune globulin;(2) Pneumococcal vaccinations that are reasonable and necessary for the prevention of illness;(3) Hepatitis B vaccinations that are reasonable and necessary for the prevention of illness for those individuals, as defined in  410.63(a) of this chapter, who are at high or intermediate risk of contracting hepatitis B;(4) Influenza vaccinations that are reasonable and necessary for the prevention of illness; and(5) COVID-19 vaccinations that are reasonable and necessary for the prevention of illness.(f)Orthopedic shoesor other supportive devices for the feet,except whenshoes are integral parts of leg braces.(g)Custodial care, except as necessaryfor the palliation or management of terminal illness, as provided in part 418 of this chapter. (Custodial care is any care that does not meet the requirements for coverage as SNF care as set forth in  409.31 through 409.35 of this chapter.)(h)Cosmetic surgery and related services,except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member.(i)Dental services(1)Basic rule. Dental servicesin connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth.(2)Exception. Except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of(i) The individual's underlying medical condition and clinical status; or(ii) The severity of the dental procedures.577