HI 00620.001 General Exclusions

No payment can be made under either the hospital insurance or SMI program for certain items and services:

1. A. 

   Not reasonable and necessary (HI 00620.010);

2. B. 

   No legal obligation to pay or provide services (HI 00620.020);

3. C. 

   Paid for by a governmental entity (HI 00620.030);

4. D. 

   Not provided within the United States (HI 00620.080);

5. E. 

   Resulting from war (HI 00620.090);

6. F. 

   Personal comfort (HI 00620.100);

7. G. 

   Routine services and appliances (HI 00620.110);

8. H. 

   Supportive devices for feet (HI 00620.120);

9. I. 

   Custodial care (HI 00620.130);

10. J. 

    Cosmetic surgery (HI 00620.140);

11. K. 

    Charges by immediate relatives or members of household (HI 00620.150);

12. L. 

    Dental services (HI 00620.160);

13. M. 

    Paid or expected to be paid under workers' compensation (HI 00620.170);

14. N. 

    Paid or expected to be paid under automobile medical or no-fault insurance or paid under liability insurance (HI 00620.175);

15. O. 

    Covered by employer plans for end-stage renal disease beneficiaries and beneficiaries age 65-69 (working aged) and their spouses age 65-69 (HI 00620.177);

16. P. 

    Excluded foot care (HI 00620.180);

17. Q. 

    Application of foot care exclusion to physicians' services(HI 00620.190)

18. R. 

    Exclusions of refractive services (HI 00620.200).