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Medicare Excluded Procedures and DiagnosesExperimental items/services or those not efficacious are excluded from coverage in all cases, regardless of patient illness, treatment history, or setting. Certain other items/services are also excluded from coverage in all cases even though needed by the patient (e.g., routine physical checkups or hearing aids). The fiscal intermediary/carrier, within the parameters of Medicare policy, has the authority to determine whether specific items/services are covered or excluded from coverage. The fiscal intermediary/carrier follows existing national Medicare policy. When no national policy exists, fiscal intermediaries/carriers may establish local coverage policy. For some items/services (e.g., cosmetic procedures, dental extraction, and some podiatric procedures), coverage depends upon meeting specific conditions of medical necessity and reasonableness, such as type and severity of illness. The fiscal intermediary refers inpatient claims involving items/services that require a medical necessity determination to NMMRA before the claims can be considered covered and payment can be made. For those cases, NMMRA reviews the medical record only for the reason for the referral. Hospitals, when requesting QIO review for excluded procedures, must submit copies of remittance advice UB92 and the complete medical record. Note: National and local medical review policies pertaining to Medicare Part A and Part B can be found at the Web site of the Medicare TrailBlazer Health Enterprises (a CMS contracted Medicare Administrative Contractor for New Mexico) [opens in new window], or WPS Medicare for former Mutual of Omaha Medicare Providers (a CMS contracted fiscal intermediary for New Mexico).
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