Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery or dental medicine (within the limitations in C.), doctor of podiatric medicine (within the limitations in D.), or doctor of optometry (within the limitations of F.), or a chiropractor (within the limits of G.), legally authorized to practice by a State in which the individual performs this function. The services performed by a physician within these definitions are subject to any limitations imposed by the State on the scope of practice.

In all States, the issuance by the State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine. If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, such local standards will be issued in determining whether a particular physician has legal authorization. If State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within these limitations will be covered.

The requirement that a doctor of medicine must be legally authorized to practice medicine and surgery by the State in which the individual performs services is met where a physician is licensed by the State to practice medicine and surgery.

A doctor of osteopathy who is legally authorized to practice medicine and surgery by the State in which the individuals performs services qualifies as a physician. In addition, a licensed osteopath or osteopathic practitioner qualifies as a “physician” to the extent that the individual performs services within the scope of the practice as defined by State law. For example, in some States osteopaths and osteopathic practitioners are limited in their practice to the manipulation of bones and muscles; such legally authorized services are covered.

A dentist is a “physician” under the health insurance program if the individual is a doctor of dental surgery or dental medicine legally authorized to practice dentistry by the State in which the individual performs services. However, a dentist is a physician only with respect to surgery related to the jaw or any structure contiguous to the jaw, or the reduction of any fracture of the jaw or any facial bone. In general, “the jaw or any structure contiguous to the jaw” includes structures of the facial area below the eyes; e.g., mandible, teeth, gums, tongue, palate, salivary glands, sinuses, etc.

Because of the general exclusion of payment for dental services, payment for the services of dentists is also limited to those surgical procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth. The coverage or exclusion of any given dental service is not affected by the professional designation of the “physician” rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine.

Effective with admissions on or after 1/1/73, the 1972 Amendments authorize the dentist caring for the patient to certify (without corroborating certification by a physician) that because of the patient's underlying medical condition and clinical status, the patient requires hospitalization for performance of excluded dental procedures.

A podiatrist is included within the definition of “physician” but only with respect to those functions which the podiatrist is legally authorized to perform in the State in which the individualperforms them. This means that the professional services provided by a podiatrist within the scope of applicable State license (except those services which are specifically excluded) are “physician's services” reimbursable on a reasonable charge basis under Part B.

Podiatrists may hold any of the following professional degrees of which the first three are the most common: Pod.D or D.P. (Doctor of Podiatry), D.S.C. (Doctor of Surgical Chiropody), D.P.M. (Doctor of Podiatric Medicine), D.S.P. (Doctor of Surgical Podiatry), Graduate in Podiatry, Master Chiropodist, Graduate Chiropodist, or in a very few instances another podiatry degree. Within a particular State, all individuals holding any of these degrees are licensed to perform the same functions; however, there are variations from State to State as to the authorized scope of podiatric practice.

A podiatrist is considered a “physician” for any of the following purposes:

1. 1. 

   for making the required physician certification and recertifications of the medical necessity for Part A and Part B provider services;

2. 2. 

   for the purpose of establishing and periodically reviewing a home health plan of treatment; and for purposes of constituting a member of a Utilization Review (UR) committee but only if:

   1. a. 

      the performance of these functions is consistent with the policy of the institution or agency with respect to which the podiatrist performs them;

   2. b. 

      the podiatrist is legally authorized by the State to perform such functions; and

   3. c. 

      at least two of the physicians on the UR committee are doctors of medicine or osteopathy.

There are many physicians performing services in hospitals operated by the Federal Government—military hospitals, Veterans Administration hospitals, and Public Health Service hospitals. Normally the services provided by a physician in a Federal hospital are not reimbursable except when the hospital provides services to the public generally as a community institution. Such a physician working in the scope of Federal employment may be considered as coming within the statutory definition of “physician” even though the individual may not have a license to practice in the State in which the individual is employed.

A doctor of optometry, legally authorized to practice optometry by the State in which the individual performs such function, becomes a “physician” as defined in the law but only for the purpose of attesting to the patient's need for prosthetic lenses. Thus, payment may be made for necessary prosthetic lenses whether prescribed by an optometrist or other physician authorized to do so. This change applies to claims for prosthetic lenses furnished on and after October 30, 1972.