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   Not covered under any condition
Ambulance mileage Mileage for ambulance transport beyond nearest facility or to/from facility preferred by member and/or family Not covered under any condition
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
Not covered under any condition
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)   Not covered under any condition
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 in the office other than services explained in Chapter 4, Section 2.1 of the Medical Benefits Chart Not covered under any condition
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
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 of the medical benefits chart in the Evidence of Coverage. If the member purchased the Enhanced Vision, Dental, and Hearing 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
Not covered under any condition
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
May be covered if member has purchased the optional Enhanced Vision, Dental & Hearing package,which is an optional supplemental benefit. See Chapter 4, Section 2.2 of the Evidence of Coverage for details.
Homemaker services Includes household assistance, light housekeeping or light meal preparation
Not covered under any condition
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   Not covered under any condition
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
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 reoccurrence 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   Not covered under any condition
Surgical leggings   Not covered under any condition
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 If the member has purchased the optional Enhanced Vision, Dental, and Hearing supplemental benefit* for an extra premium, routine vision services are covered. See Chapter 4, Section 2.2 of the Evidence of Coverage 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

*Services may be available if the member has purchased the Enhanced Vision, Dental & Hearing package for an extra premium. Benefits are administered through EyeMed, Delta Dental, or Priority Health Medicare for hearing providers. Go to Member Inquiry and use the Supplemental Benefits menu to see if the member has this package.