Not Medically Necessary Services
Medicare does not pay for services that are not considered reasonable and necessary for the diagnosis or treatment of an illness or injury. When such services are planned, physicians should ask the patient to sign an Advance Beneficiary Notice.
Services that are not medically necessary include but are not limited to:
* Services provided in a hospital or Skilled Nursing Facility (SNF) that, based on the patient ’ s condition, could have been provided elsewhere (e.g., the patient ’ s home or a nursing home);
* Hospital or SNF services exceeding Medicare limitations regarding length of stay;
* E/M services in excess of those considered medically reasonable and necessary;
* Therapy or diagnostic procedures in excess of Medicare usage limits; or
* Services not warranted based on the diagnosis of the patient.
Bundled or Basic Allowance Services
Services included in the basic allowance of another procedure are considered bundled services and may not be charged to the patient. These services include but are not limited to:
* Fragmented services included in the basic allowance of the initial service;
* Prolonged care (indirect); Physician standby services;
* Case management services (such as telephone calls to and from patients); and
* Supplies included in the basic allowance of a procedure.
