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 he/she 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  
Acupuncture   Not covered under any condition  
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  
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: 

  • 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. 

 
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***   Not covered under any condition: Outpatient facility & professional dental expenses for routine dental services. Covered: 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  
Detox in an outpatient setting   Not covered under any condition  
Diagnostic lab tests   Not covered under any condition: Diagnostic lab tests that are not medically necessary under Medicare coverage criteria  
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   Not covered under any condition: Part D drugs purchased from or obtained while in another country, including those obtained on a cruise ship. These are considered non-FDA approved. 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  Repairs or modifications of aids and/or supplies (batteries) Not covered under any condition  
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
Not covered under any condition  
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  
Methadone outpatient clinics   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.