Medicare Advantage plan EOC exclusions

When a service is specifically excluded from coverage in a Medicare Evidence of Coverage (EOC) document, you may provide the service IF you:

1. Tell the member that their plan's EOC specifically states that the service is not covered.
2. Tell the member that they will bear 100% of the cost of the service.
3. Bill the service with the GY modifier to ensure the claim goes to member liability.

Learn how you or the member can request a pre-service coverage determination (PSOD).

Forms are not required

No form is necessary. Your verbal explanation to the member, documented in the patient's record, is sufficient.

Services excluded from coverage

In addition to the services listed in the table below, services are not covered when:

• The service is not reasonable and medically necessary, according to the standards of Original Medicare. See Chapter 9 of the Evidence of Coverage for how to obtain a coverage decision.
• The service is provided in a Veteran's Affairs (VA) facility
• The service or item is needed due to or related to injuries caused by war or an act of war
• The treatment or service is provided by a person who is not licensed to provide those services, or who is not operating within the scope of that license

Service	Description of service	Coverage
Adaptive equipment		May be covered under the member's over-the-counter allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart
Ambulance mileage	Mileage for ambulance transport beyond nearest facility or to/from facility preferred by member and/or family	May be covered under the member's worldwide assistance program. See Chapter 4, Section 2.1, Medical Benefits Chart
Assistive listening devices	Including but not limited to telephone amplifiers and alerting devices	Not covered under any condition
Athletic clothes and shoes		Not covered under any condition
Bathroom safety devices	Including but not limited to lifts, raised toilet seats, bidet toilet seats, transfer benches, grab bars, and parallel bars	May be covered under the member's over-the-counter allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart
Beds	Including but not limited to oscillating mattresses, bed baths (home type), bed boards, lifters (elevator), lounges (power or manual	Not covered under any condition
Blood glucose analyzers	Reflectance colorimeter	Not covered under any condition
Chair portion of chair lift system		Not covered under any condition
Chiropractic care	Maintenance care, x-ray, labs, and any other service performed within the office	Routine chiropractic services covered under the member's plan*** are described in Chapter 4, Section 2.1, Medical Benefits Chart
Companion and concierge care		Not covered under any condition
Continuous glucose monitoring (CGM) devices		Covered: Medicare-approved devices only. Priority Health will determine if the member meets medically-necessary criteria.
Cosmetic surgery or procedures		Covered after an accidental injury, or to improve a malformed part of the body. Covered for all stages of reconstruction for a breast after mastectomy, as well as for the unaffected breast to product a symmetrical appearance.
Counseling services	Including but not limited to geriatric day care programs, individual psychophysiological therapy including biofeedback, marriage counseling, pastoral counseling	Not covered under any condition
Cruise ship services		Medicare may cover medically necessary health care services received by the member on a cruise ship in the following situations:  The doctor is allowed under certain laws to provide medical services on the cruise ship The ship is in a U.S. port or no more than 6 hours away from the U.S. port when services are received, regardless of whether it's an emergency.  Medicare doesn't cover health care services received when the ship is more than 6 hours away from a U.S. port.
Custodial care	See Chapter 12, Definitions of important words for custodial care	Not covered under any condition
Dental services, non-routine, Medicare covered		Inpatient or outpatient dental care required to treat illness or injury may be covered as inpatient or outpatient care. Priority Health will determine if the member meets the medically necessary Medicare criteria
Dental services, routine, not Medicare covered**	Outpatient facility and professional dental expenses for routine dental services	Routine dental services covered under the medical plan are described in Chapter 4, Section 2.1, Medical Benefits chart. If the member purchased the Enhanced Dental and Vision package, which is an optional supplemental benefit for an extra premium, additional dental services are covered, see Chapter 4, Section 2.2 of the Evidence of Coverage for details
Drugs, Part B	Non-chemotherapy drugs and biologicals used for conditions not approved by Food and Drug Administration (FDA), such as biomedical hormones, and not covered under Medicare	Not covered under any condition
Drugs, Part D	Part D drugs purchased from or obtained while in another country, including those obtained on a cruise ship. These are considered non-FDA approved.	Not covered under any condition. Self-administered drugs may be covered when provided in an outpatient setting such as an outpatient hospital, ER room or physician office. See also Chapter 4, Section 2.1, Medical Benefits Chart and Chapter 12, Definitions and important words.
Emergency communications systems	Includes personal emergency response systems (PERS), medical alert devices, in-home telephone alert systems	May be covered under the member's plan. See Chapter 4, Section 2.1, Medical Benefits Chart.
Experimental or investigational medical and surgical procedures, equipment and medications	Experimental procedures and items are those determined by our plan and Original Medicare to not be generally accepted by the medical community	May be covered by Original Medicare under a Medicare-approved clinical research study or by our plan. See Chapter 3, Section 5 for more information on clinical research studies.
FDA exclusions	Services not approved by the federal Food & Drug Administration	Not covered under any condition
Fees charged by immediate family/household members		Not covered under any condition
Fitness equipment rentals		Not covered under any condition
Foot care, routine		Some limited coverage provided according to Medicare guidelines (e.g., if member has diabetes). PriorityMedicare D-SNP includes routine foot care, outside of original Medicare guidelines.
Full-time nursing care in-home		Not covered under any condition
Gender reassignment	Surgery and gender reassignment hormones	Covered if determined by Priority Health to meet medical necessity criteria
Hearing services, routine, not covered by Medicare	Hearing aid exams, hearing aids and hearing aid evaluations including the fitting and checking of hearing aids	Routine hearing services covered under the member's plan are described in Chapter 4, Section 2.1, Medical Benefits Chart.
Homemaker services	Includes household assistance, light housekeeping or light meal preparation	May be covered under the member's Companion Care benefit, if plan includes this benefit**. See Chapter 4, Section 2.1, Medical Benefits Chart
Homeopathic services		Not covered under any condition
Immunizations (when covered under Part D)	Immunizations covered under Part D benefits, including but not limited to Shingrix, and tetanus (when not used to treat an injury or illness)	Members should be directed to their pharmacy for Part D immunizations. Plan will not reimburse if dispensed in a doctor's office.
Incontinence pads/supplies		May be covered under the member's over-the-counter allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart
Knee walker		May be covered under OTC depending on the member's plan
Lab tests	Not medically necessary under Medicare coverage criteria	May be covered under the Personalized Health Risk Assessment benefit on PriorityMedicare Thrive and PriorityMedicare Thrive Plus. See Chapter 4, Section 2.1 for details. All other plans - routine: Not covered under any condition when ordered solely as part of an annual physical exam and not to diagnose a medical condition
Lift chair	The lifting mechanism of a lift chair only	The lifting mechanism may be covered if determined by Priority Health to meet medically necessary criteria. Chair/recliner portion is not covered under any condition.
Long-term care		Not covered under any condition
Massage therapy		Not covered under any condition, when performed by a massage therapist
Meals delivered to the home		Not covered under any condition
Naturopathic services		Not covered under any condition
Orthopedic shoes or supportive devices for the feet		Shoes that are part of a leg brace and are included in the cost of the brace. Orthopedic or therapeutic shoes for people with diabetic foot disease. May also be covered under your over-the-counter allowance. See Chapter 4, Section 2.1, Medical Benefits Chart.*
Personal in-room items		Not covered under any condition at a hospital or skilled nursing facility, including but not limited to a telephone or television
Physical exams and other services required by third parties	Exams/services for purposes such as obtaining or maintaining employment, participation in employee programs, insurance or licensing, sports participation, on court order, or when required for parole or probation	Not covered under any condition
Private-duty nurses		Not covered under any condition
Private room		Not covered when semi-private rooms are available
Precluded Providers	Services from providers who appear on the CMS Preclusion List. See Chapter 12, Definitions of important words, for CMS Preclusion list.	Not covered under any condition.
Pre-operative testing	Including but not limited to lab tests, X-rays, EKGs, EEGs, and cardiac monitoring, when performed strictly for pre-operative clearance when no underlying medical condition exists for testing	Not covered under any condition
Residential treatment		Not covered under any condition when the main purpose is to remove the member from his/her environment to prevent the re-occurrence of a condition such as but not limited to eating disorders, alcohol addiction, etc.
Reversal of sterilization		Not covered under any condition
Smart devices	Including smart phones, tablets, personal computers, etc. and the cost of applications	Not covered under any condition
Sporting good merchandise	Camping gear, rackets/paddles, hiking/fishing poles and golf clubs	Not covered under any condition
Structural modifications	Including but not limited to ramps, doorways, elevators and stairway elevators	Not covered under any condition
Support hose		May be covered under the member's over-the-counter (OTC) allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart
Surgical leggings		May be covered under the member's over-the-counter (OTC) allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart
Temporomandibular joint syndrome (TMJ) treatment		Not covered on Individual MAPD and DSNP plans. May be covered on some Employer Group plans. See Chapter 4, Section 2.1, Medical Benefits Chart in Evidence of Coverage.
Transportation	Including commercial or private air transport, car, taxi, bus, gurney van and wheelchair van, even if it is the only way to travel to a network provider	May be covered by a member's Companion Care benefit depending on plan. See Chapter 4, Section 2.1, Medical Benefits Chart. Also may be covered as part of the Transportation benefit if the member has a DSNP plan.
VA services	Services provided to veterans in Veterans Affairs (VA) facilities	Not covered under any condition
Vision services, routine, not covered by Medicare	Eye exams, eyewear, refraction, retinal imaging, and fitting of eyewear	Routine vision services covered under the member's plan are described in Chapter 4, Section 2.1, Medical Benefits Chart. If the member has purchased the enhanced dental and vision package, which is an enhanced optional benefit for an extra premium, additional vision services are covered. See Chapter 4, Section 2.2 for details.
Vision services, routine, not covered by Medicare**	Refractive surgical procedures laser astigmatism correction, radial keratotomy and keratoplasty to treat refractive defects, LASIK or LASEK surgery, keratophakia and keratomileusis, nonconventional intraocular lenses (IOLs) following cataract surgery (for example, a presbyopia-correcting IOL)	Not covered under any condition
War related	Items or services needed whether due to or related to injuries caused by war or an act of war	Not covered under any condition
Weight loss treatment	Including but not limited to medications, self-help groups, non-Medicare covered weight loss programs, meal programs and dietary supplements	Nutrition support services may be covered on PriorityMedicare Thrive and PriorityMedicare Thrive Plus. See Chapter 4, Section 2.1 for more details. Not covered under any condition on all other plans.
Wigs		Not covered under any condition

*Over-the-counter allowance included on PriorityMedicare Key, PriorityMedicare Edge, PriorityMedicare Vital, PriorityMedicare Thrive,PriorityMedicare Thrive Plus , PriorityMedicare Value and PriorityMedicare D-SNP plans. Allowances may be monthly or quarterly and vary by plan. See Chapter 4, Section 2.1, Medical Benefits Chart for more information. 

**Services may be available if the member has purchased the enhanced dental and vision package for an extra premium (not available to PriorityMedicare D-SNP members). Benefits are administered through EyeMed and Delta Dental. Go to Member Inquiry and use the Supplemental Benefits menu to see if the member has this package.

***Routine chiropractic services included on  PriorityMedicare Key, PriorityMedicare Vintage PriorityMedicare Edge, PriorityMedicare Vital, PriorityMedicare Thrive, PriorityMedicare Thrive Plus, PriorityMedicare D-SNP plans and some Medicare employer group plans. See Chapter 4, Section 2.1, Medical Benefits Chart for more information.