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:
- Tell the member that their plan's EOC specifically states that the service is not covered.
- Tell the member that he/she will bear 100% of the cost of the service.
- 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|
|Acupuncture||The selection and manipulation of specific acupuncture points through the insertion of needles or "needling," or other "non-needling" techniques focused on these points.||Up to 12 visits covered for members with chronic low back pain (cLBP). See Provider Manual: Medical/surgical services - Acupuncture, Medicare|
|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|
|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|
|Blood pressure cuff (i.e. pulse tachometer)||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.|
|Chair portion of chair lift system||Not covered under any condition|
|Chiropractic care, not Medicare covered||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 2, Section 2.1, Medical Benefits Chart|
|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.|
|Cruise ship services||
Medicare may cover medically necessary health care services received by the member on a cruise ship in the following situations:
Medicare doesn't cover health care services received when the ship is more than 6 hours away from a U.S. port.
|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|
|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|
|Diagnostic lab tests||Diagnostic lab tests that are not considered medically necessary under Medicare coverage criteria||Not covered under any condition|
|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|
|Emergency communications systems||Includes personal emergency response systems (PERS), medical alert devices, in-home telephone alert systems||Not covered under any condition|
|Experimental or investigational clinical trials/services||See Chapter 3, Section 5.1 of the Evidence of Coverage
||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 Food & Drug Administration||Not covered under any condition|
|Fees charged by immediate family/household members||Not covered under any condition|
|Foot care, routine||Some limited coverage provided according to Medicare guidelines (e.g., if you have diabetes)|
|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)||Including but not limited to Zostavax
||May be eligible for reimbursement under the member's prescription drug coverage.|
|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||Not covered under any condition|
|Lab tests, 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||Covered if determined by Priority Health to meet medically necessary criteria. Chair/recliner portion is not covered|
|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|
|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
|Pre-operative testing||Including but not limited to lab tests, X-rays, EKGs, EEGs, and cardiac monitoring, when performed strictly for pre-operative clearance 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|
|Sales tax||Sales tax on medical services and/or items and prescription drugs||Not covered under any condition|
|Smart devices||Including smart phones, tablets, personal computers, etc. and the cost of applications||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 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 allowance, if plan includes this benefit*. See Chapter 4, Section 2.1, Medical Benefits Chart
|Temporomandibular joint syndrome (TMJ) treatment||Not covered under any condition
|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||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|
|Vision, low-vision aids||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||Not covered under any condition|
|Wigs||Not covered under any condition|
*Over-the-counter allowance included on PriorityMedicare Key, PriorityMedicare Edge, PriorityMedicare Ideal, PriorityMedicare Value and PriorityMedicare D-SNP plans. Quarterly allowance amounts vary by plan. See Chapter 4, Section 2.1, Medical Benefits Chart for more information.
**Members with PriorityMedicare Edge and PriorityMedicare Ideal plans may qualify for companion care coverage. 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. 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 Edge and PriorityMedicare Ideal plans. See Chapter 2, Section 2.1, Medical Benefits Chart for more information.
Evidence of Coverage (EOC)
The Evidence of Coverage is the legal, detailed description of benefits and costs for the plan year. It also explains the rights and rules your client will need to follow when using coverage for medical care and prescription drugs. Download the EOC booklets here.