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Routine ABN Prohibition Exceptions


ABNs may be routinely given to beneficiaries and considered to be effective notices which will protect notifiers in the following exceptional circumstances:

A. Services Which Are Always Denied for Medical Necessity 

In any case where a national coverage decision provides that a particular service is never covered, under any circumstances, as not reasonable and necessary under §1862(a)(1) of the Act (e.g., at present, all acupuncture services by physicians are denied as not reasonable and necessary), an ABN that gives as the reason for expecting denial that: “Medicare never pays for this item/service” may be routinely given to beneficiaries, and no claim need be submitted to Medicare. If the beneficiary demands that a claim be submitted to Medicare, the notifier should submit the claim as a demand bill.

B. Experimental Items and Services 

When any item or service which Medicare considers to be experimental (e.g., “Research Use Only” and “Investigational Use Only” laboratory tests) is to be furnished, since all such services are denied as not reasonable and necessary under §1862(a)(1) of the Act because they are not proven safe and effective, the beneficiary may be given an ABN that gives as the reason for expecting denial that: “Medicare does not pay for services which it considers to be experimental or for research use.” Alternative, more specific, language with respect to Medicare coverage for clinical trials may be substituted as necessary as the ABN’s reason for expecting denial.

C. Frequency Limited Items and Services 

When any item or service is to be furnished for which Medicare has established a statutory or regulatory frequency limitation on coverage, or a frequency limitation on coverage on the basis of a national coverage decision or on the basis of the contractor’s local medical review policy (LMRP), because all or virtually all beneficiaries may be at risk of having their claims denied in those circumstances, the notifier may routinely give ABNs to beneficiaries. In any such routine ABN, the notifier must state the frequency limitation as the ABN’s reason for expecting denial (e.g., “Medicare does not pay for this item or service more often than frequency limit”).

D. Medical Equipment and Supplies Denied Because the Supplier Had No Supplier Number or the Supplier Made an Unsolicited Telephone Contact

Given that Medicare denials of payment under §1834(j)(1) of the Act on the basis of a supplier’s lack of a supplier number, and under §1834(a)(17)(B) of the Act, the prohibition on unsolicited telephone contacts, apply to all varieties of medical equipment and supplies and to all Medicare beneficiaries equally, the usual prohibition on provision of routine notices to all beneficiaries does not apply in these cases.

NOTE: A routine ABN, like any other ABN, is effective only for the reason for expecting denial that is specified on the ABN. Such a routine ABN will not be effective notice, that is, will not shift liability to the beneficiary, in the case of any Medicare denial of the claim for any reason other than that specified on the ABN.

Reference: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf

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