CMS Pub. 100-04, ch. 30, § 20.2.1

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 physician’s 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 physician’s 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.