CMS Pub. 100-02, ch. 1, § 120

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 because 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 complications 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 are 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 services 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 services, 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 subsequent 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 for evaluating

the patient's progress, these visits are not covered.