CMS Pub. 100-02, ch. 16, § 90

Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the

purpose of prescribing, fitting, or changing eyeglasses; eye refractions 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 apply 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 abdominal 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 individual 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 Other 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. Immunizations

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 covered 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)