Medicare's exclusions are set by statute, not by opinion. Every answer below is what federal rules say, quoted and linked to its source, with the date we last checked it. Where a Medicare Advantage plan can fill the gap, we show what plans actually filed with CMS — not what they advertise.
Medicare does not pay for an assistant at surgery for procedures where assistants are not customarily required.
“Certain services of an assistant-at-surgery.”
The exception. Assistants ARE paid for procedures where CMS data show one is used often enough to be necessary. The exclusion applies procedure by procedure.
42 CFR 411.15(n) · checked 2026-10-04
Medicare generally does not pay for health care you get outside the United States and its territories.
“Services Not Provided Within United States”
The exception. There are narrow exceptions: a medical emergency in the U.S. where a foreign hospital is closer, travel through Canada between Alaska and another state, and care aboard a ship within six hours of a U.S. port. Some Medigap policies add foreign travel emergency coverage.
Medicare Benefit Policy Manual Ch. 16 §60 · checked 2026-10-04
Where workers' compensation, no-fault, auto or liability insurance is responsible for the care, that insurer pays first and Medicare does not pay as primary.
“Services Reimbursable Under Automobile, No Fault, Any Liability Insurance or Workers' Compensation”
The exception. Medicare may pay conditionally when the other insurer will not pay promptly, and then recovers from the settlement. This is a payment-order rule, not a permanent exclusion — see the Medicare Secondary Payer rules.
Medicare Benefit Policy Manual Ch. 16 §150 · checked 2026-10-04
Medicare does not pay a bill from your spouse, parent, child, sibling or anyone living in your household, even if they are a licensed provider.
“Charges Imposed by Immediate Relatives of the Patient or Members of the Patient's Household”
The exception. The manual defines which relationships count. The exclusion follows the relationship, not the quality of the care.
Medicare Benefit Policy Manual Ch. 16 §130 · checked 2026-10-04
Medicare does not pay for devices that are still experimental or investigational.
“Experimental or investigational devices, except for certain devices.”
The exception. Certain FDA-approved investigational device exemption (IDE) category B devices and devices used in qualifying clinical trials ARE covered. The exclusion is not absolute.
42 CFR 411.15(o); Medicare Benefit Policy Manual Ch. 16 §10 · checked 2026-10-04
Services furnished to a hospital or skilled nursing facility patient must be billed by the facility, not separately by an outside supplier.
“Services to hospital patients”
The exception. This is a billing rule, not a coverage gap: the service is still covered, it simply has to come through the facility's bill. You should not receive a separate bill for it.
42 CFR 411.15(m), (p); Medicare Benefit Policy Manual Ch. 16 §170 · checked 2026-10-04
Medicare does not pay for care a federal, state or local government entity has already furnished or paid for.
“Items and Services Furnished, Paid for or Authorized by Governmental Entities”
The exception. VA, Indian Health Service, TRICARE and CHAMPVA each have their own coordination rules at §§50.1–50.5. Being a veteran does not by itself exclude you from Medicare.
Medicare Benefit Policy Manual Ch. 16 §50 · checked 2026-10-04
Medicare does not pay for care of an injury or disease caused by an act of war occurring after the beneficiary's coverage began.
“Services Resulting from War”
The exception. Service-connected conditions are generally VA responsibility. This exclusion is rarely applied in practice.
Medicare Benefit Policy Manual Ch. 16 §70 · checked 2026-10-04
If a service does not fall into one of the benefit categories Congress created, Medicare cannot pay for it no matter how beneficial it is.
“General Exclusions from Coverage”
The exception. None. This is a statutory limit, not a medical judgment, and it cannot be appealed on medical grounds.
Medicare Benefit Policy Manual Ch. 16 §10 · checked 2026-10-04
If you have a non-covered procedure, Medicare generally does not pay for the follow-up care it makes necessary either.
“Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare”
The exception. Treatment of a complication is handled differently from planned follow-up; the manual draws the line at §180.
Medicare Benefit Policy Manual Ch. 16 §180 · checked 2026-10-04
Medicare does not pay for a service that is not reasonable and necessary to diagnose or treat an illness or injury, even when a doctor orders it.
“Any services that are not reasonable and necessary for one of the following purposes”
The exception. This is the test every claim must pass, not a list. A service can be excluded here even when it is covered for someone else, because the question is whether it was reasonable and necessary for you. If Medicare denies a claim on this basis you have full appeal rights.
42 CFR 411.15(k); Medicare Benefit Policy Manual Ch. 16 §20 · checked 2026-10-04
Federal law bars Medicare payment for any item or service whose purpose is to cause, or assist in causing, a patient's death.
“Assisted suicide.”
The exception. This does not restrict hospice, palliative care or the withdrawal of treatment, all of which remain covered.
42 CFR 411.15(q) · checked 2026-10-04
Medicare does not pay when nobody has a legal obligation to pay for the service — for example a free clinic or a provider who waives the charge for everyone.
“No Legal Obligation to Pay for or Provide Services”
The exception. A provider who bills only insured patients is treated differently from one who bills nobody; the manual sets out indigence, warranty and religious-order cases separately at §§40.1–40.7.
Medicare Benefit Policy Manual Ch. 16 §40 · checked 2026-10-04
If the hospital charges separately for a television or telephone in your room, Medicare does not pay it.
“A television or phone in your room (if there's a separate charge for these items)”
The exception. Where the hospital includes them in the room rate at no separate charge, there is nothing to exclude.
42 CFR 411.15(j) · Medicare.gov — Inpatient hospital care · checked 2026-10-04
Medicare does not pay the extra cost of a private room when a semi-private room would do.
“A private room (unless medically necessary)”
The exception. A private room IS covered when it is medically necessary — isolation for infection control, for example — or when the hospital has no semi-private rooms.
42 CFR 411.15(j) · Medicare.gov — Inpatient hospital care · checked 2026-10-04
Medicare pays nothing toward room and board in an assisted living facility.
“Medicare doesn't cover custodial care if it's the only care you need.”
The exception. Medicare may still pay for covered medical services delivered to you while you live there — a doctor visit, physical therapy, or home health if you qualify. It is the room, board and personal care that are excluded.
42 CFR 411.15(g); Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — Nursing home care · checked 2026-10-04
Original Medicare does not pay for meals delivered to your home.
“Home meal delivery”
The exception. Many Medicare Advantage plans file a meal benefit, usually a short post-discharge course rather than ongoing meals.
Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — Home health services · checked 2026-10-04
Shopping, cleaning and laundry are not covered when they are unrelated to your plan of care.
“Homemaker services (like shopping and cleaning) unrelated to your care plan”
The exception. Where such help IS part of a covered home health plan of care, it is not excluded. The qualifier in the rule is “unrelated to your care plan”.
Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — Home health services · checked 2026-10-04
The hospice benefit does not pay room and board where you live, whether that is your home, a nursing home or a hospice facility.
“Medicare doesn't cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility.”
The exception. When the hospice team arranges short-term inpatient care or respite care, Medicare DOES cover that stay.
42 CFR 411.15(g); Medicare Benefit Policy Manual Ch. 16 §110.1 · Medicare.gov — Hospice care · checked 2026-10-04
Original Medicare does not cover non-medical long-term care — help with bathing, dressing, eating or using the bathroom, whether at home or in a nursing home. This is the largest uncovered exposure in Medicare.
“Non-medical long-term care”
The exception. Medicare covers skilled nursing facility care for a limited period after a qualifying hospital stay, and skilled home health care — both only while skilled care is needed, never for custodial care alone.
42 CFR 411.15(g); Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — What's not covered · checked 2026-10-02
Help with bathing, dressing, eating or using the bathroom is not covered when it is the only help you need.
“Custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need”
The exception. The same help IS covered as part of a home health plan of care when you also need skilled nursing or therapy and meet the homebound test. The word that decides it is “only”.
42 CFR 411.15(g); Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — Home health services · checked 2026-10-04
Items for comfort rather than treatment are not covered.
“Personal comfort services, except as necessary for the palliation or management of terminal illness as provided in part 418 of this chapter.”
The exception. Under the hospice benefit, comfort IS the treatment — personal comfort items are covered there.
42 CFR 411.15(j); Medicare Benefit Policy Manual Ch. 16 §80 · checked 2026-10-04
Medicare does not pay for a private-duty nurse.
“Private-duty nursing”
The exception. Skilled nursing provided by the facility or by a Medicare-certified home health agency under a plan of care is covered. It is the privately hired nurse that is excluded.
Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — Inpatient hospital care · checked 2026-10-04
Medicare does not pay for 24-hour-a-day care in your home.
“24-hour-a-day care at your home”
The exception. Intermittent skilled nursing and home health aide visits are covered when you qualify — generally fewer than 7 days a week, or less than 8 hours a day over 21 days.
Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — Home health services · checked 2026-10-04
Part A covers up to 100 days of skilled nursing facility care in a benefit period. From day 101 you pay the entire cost.
“Days 101 and beyond: You pay all costs.”
The exception. The 100 days reset when a new benefit period begins — after 60 consecutive days with no inpatient or skilled care. Days 21 to 100 already carry a daily coinsurance.
Medicare Benefit Policy Manual Ch. 16 §110 · Medicare.gov — Skilled nursing facility care · checked 2026-10-04
Original Medicare does not cover routine dental care — cleanings, fillings, extractions, or dentures.
“In most cases, Original Medicare doesn't cover dental services like routine cleanings, filings, tooth extractions, or items like dentures”
The exception. Medicare may cover dental services that are part of a covered medical procedure: heart valve repair or replacement, an organ transplant, cancer-related treatment, or dialysis for End-Stage Renal Disease.
42 CFR 411.15(i); Medicare Benefit Policy Manual Ch. 16 §140 · Medicare.gov — What's not covered · checked 2026-10-02
Original Medicare does not pay for dentures or for most dental implants.
“Dental services”
The exception. Where a dental procedure is an integral part of a covered medical treatment — jaw reconstruction after an accident, or dental work required before a transplant, cardiac valve procedure, or head-and-neck cancer treatment — it can be covered.
42 CFR 411.15(i); Medicare Benefit Policy Manual Ch. 16 §140 · Medicare.gov — What's not covered · checked 2026-10-04
The exam to prescribe, fit or change a hearing aid is excluded along with the aid itself.
“Hearing aids or examinations for the purpose of prescribing, fitting, or changing hearing aids.”
The exception. Diagnostic hearing and balance exams ARE covered under Part B when a provider orders them to decide whether you need medical treatment, and you may see an audiologist once every 12 months without an order for non-acute hearing conditions.
42 CFR 411.15(d); Medicare Benefit Policy Manual Ch. 16 §100 · Medicare.gov — Hearing & balance exams · checked 2026-10-04
Original Medicare does not usually cover eyeglasses or contact lenses.
“Medicare Part B (Medical Insurance) doesn't usually cover eyeglasses or contact lenses”
The exception. ONE pair of eyeglasses with standard frames, or one set of contact lenses, after each cataract surgery that implants an intraocular lens — from a supplier that participates in Medicare. You pay 20% after the deductible, plus any upgrade on the frames.
42 CFR 411.15(b) · Medicare.gov — Eyeglasses & contact lenses · checked 2026-10-02
Original Medicare does not cover hearing aids, or the exams to fit them. You pay the full cost.
“Medicare doesn't cover hearing aids or exams for fitting hearing aids”
The exception. Diagnostic hearing and balance exams ARE covered under Part B when your provider orders them to find out if you need medical treatment. You may also see an audiologist once every 12 months without an order, for non-acute hearing conditions. You pay 20% after the Part B deductible.
42 CFR 411.15(d); Medicare Benefit Policy Manual Ch. 16 §100 · Medicare.gov — Hearing aids · Medicare.gov — Hearing & balance exams · checked 2026-10-02
Devices that use lenses to aid vision or provide magnification are excluded, whatever their size, form or technology.
“all devices irrespective of their size, form, or technological features that use one or more lens to aid vision or provide magnification”
The exception. Prosthetic lenses after surgical removal of the eye's lens ARE covered, as is one pair of conventional eyeglasses or contact lenses after cataract surgery with an intraocular lens implant.
42 CFR 411.15(b) · checked 2026-10-04
Routine fillings and simple tooth extractions are not covered by Original Medicare.
“Dental services”
The exception. An extraction required to prepare the jaw for radiation treatment of neoplastic disease, or as part of another covered medical procedure, can be covered.
42 CFR 411.15(i); Medicare Benefit Policy Manual Ch. 16 §140 · Medicare.gov — What's not covered · checked 2026-10-04
Orthopedic shoes and other supportive devices for the feet are not covered.
“Orthopedic shoes or other supportive devices for the feet, except when shoes are integral parts of leg braces.”
The exception. Two real exceptions: shoes that are an integral part of a leg brace, and therapeutic shoes and inserts for people with diabetes who meet the qualifying conditions, which are covered under a separate benefit.
42 CFR 411.15(f) · checked 2026-10-04
Original Medicare does not pay for a routine dental check-up or cleaning.
“Dental services”
The exception. Preventive dental is one of the most commonly filed Medicare Advantage extras, though what it pays for varies widely by plan.
42 CFR 411.15(i); Medicare Benefit Policy Manual Ch. 16 §140 · Medicare.gov — What's not covered · checked 2026-10-04
Original Medicare does not cover routine eye exams for prescription glasses.
“Eye exams (for prescription eyeglasses)”
The exception. Medical eye care is covered: glaucoma screening for people at high risk, diabetic retinopathy screening, and treatment of eye disease and injury.
42 CFR 411.15(c) · Medicare.gov — What's not covered · checked 2026-10-02
Cutting nails, removing corns and calluses and routine foot hygiene are excluded when there is no localized illness, injury or symptom involving the feet.
“Routine foot care, such as the cutting or removal of corns, or calluses, the trimming of nails, routine hygienic care (preventive maintenance care ordinarily within the realm of self care), and any service performed in the absence of localized illness, injury, or symptoms involving the feet.”
The exception. Treatment of warts is not excluded. Mycotic toenail treatment may be covered no more often than every 60 days. And the same care IS covered when it is part of a covered foot procedure, or when it is the initial diagnostic service for a symptom that might come from a treatable condition — which is how people with diabetes commonly qualify.
42 CFR 411.15(l)(1)(i); Medicare Benefit Policy Manual Ch. 16 §30 · Medicare.gov — Foot care · checked 2026-10-04
Evaluation or treatment of flattened arches is excluded, and so is prescribing supportive devices for them — regardless of the underlying cause.
“The evaluation or treatment of flattened arches (including the prescription of supportive devices) regardless of the underlying pathology.”
The exception. None stated for flat feet specifically. Treatment of subluxations of the feet is excluded on the same terms at (l)(1)(ii).
42 CFR 411.15(l)(1)(iii) · checked 2026-10-04
Original Medicare covers acupuncture only for chronic low back pain — nothing else.
“Medicare Part B (Medical Insurance) only covers acupuncture (including dry needling) for chronic low back pain”
The exception. Up to 12 treatments in 90 days; 8 more if you improve, to a maximum of 20 in 12 months. If you are not improving, Medicare stops covering it and you pay 100%. You pay 20% after the Part B deductible.
42 CFR 411.15(k) · Medicare.gov — Acupuncture · checked 2026-10-02
Original Medicare pays nothing toward incontinence supplies or adult diapers.
“Original Medicare doesn't cover incontinence supplies or adult diapers.”
The exception. Some Medicare Advantage plans include them in an over-the-counter allowance. Ask the plan what the allowance actually buys.
42 CFR 411.15(k) · Medicare.gov — Incontinence supplies & adult diapers · checked 2026-10-04
An ambulance is covered only when travelling any other way could endanger your health.
“traveling in any other vehicle could endanger your health, and you need medically necessary services”
The exception. Medicare also limits payment to the nearest appropriate facility able to give you the care you need. A longer trip to a preferred hospital is generally your cost.
42 CFR 411.15(k) · Medicare.gov — Ambulance services · checked 2026-10-04
If your doctor has formally opted out of Medicare, Medicare pays nothing toward their care and you pay the full amount under a private contract.
“Covered items or services you get from a doctor or other provider that has opted out of participating in Medicare (except in the case of an emergency or urgent need)”
The exception. Emergency and urgently needed care from an opted-out provider is the stated exception.
Medicare Benefit Policy Manual Ch. 16 §40 · Medicare.gov — What's not covered · checked 2026-10-04
Part B covers only manual manipulation of the spine to correct a subluxation. Anything else a chiropractor orders is not covered.
“Medicare doesn't cover other services or tests a chiropractor orders, including X-rays, massage therapy, and acupuncture.”
The exception. The spinal adjustment itself IS covered when performed by hand or with an activator device to correct a subluxation.
42 CFR 411.15(k) · Medicare.gov — Chiropractic services · checked 2026-10-04
A membership or retainer fee charged by a concierge practice is not covered.
“also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care”
The exception. The covered medical services that practice provides are still billable to Medicare. It is the membership fee itself that you pay.
Medicare Benefit Policy Manual Ch. 16 §40 · Medicare.gov — What's not covered · checked 2026-10-04
Original Medicare does not cover cosmetic surgery.
“Cosmetic surgery”
The exception. Reconstructive surgery after an accidental injury, or to improve the function of a malformed body part, is a covered medical service rather than cosmetic.
42 CFR 411.15(h); Medicare Benefit Policy Manual Ch. 16 §120 · Medicare.gov — What's not covered · checked 2026-10-02
An examination you are made to have by an insurance company, an employer or a government agency is not covered.
“Examinations required by insurance companies, business establishments, government agencies, or other third parties.”
The exception. None. Whoever requires the exam is expected to pay for it.
42 CFR 411.15(a)(2) · checked 2026-10-04
Original Medicare does not cover gym memberships or fitness programs.
“Original Medicare doesn't cover gym memberships or fitness programs”
The exception. Medicare.gov itself points to the exception: these “may be part of the extra coverage offered by Medicare Advantage Plans, other Medicare health plans, or Medicare Supplement Insurance (Medigap) plans.”
42 CFR 411.15(k) · Medicare.gov — Gym memberships & fitness programs · checked 2026-10-04
Original Medicare does not cover massage therapy.
“Massage therapy”
The exception. Medicare does cover physical therapy, which is a different benefit with its own qualifying conditions. Massage ordered by a chiropractor is explicitly excluded.
42 CFR 411.15(k); Medicare Benefit Policy Manual Ch. 16 §20 · Medicare.gov — What's not covered · checked 2026-10-04
Part B does not cover immunizations as a general benefit.
“Immunizations, except for —”
The exception. Named exceptions are covered in full: influenza, pneumococcal, hepatitis B for people at medium or high risk, and any vaccine needed to treat an injury or direct exposure. Most other vaccines, including shingles and RSV, run through Part D instead and are now available with no cost sharing.
42 CFR 411.15(e) · checked 2026-10-04
Medicare does not pay for getting to a medical appointment by car, taxi or rideshare.
“Medicare will only cover ambulance services to the nearest appropriate medical facility that's able to give you the care you need.”
The exception. Ambulance transport IS covered where travelling any other way would endanger your health. Non-emergency transport is one of the more common Medicare Advantage extras, though far from universal.
42 CFR 411.15(k) · Medicare.gov — Ambulance services · checked 2026-10-04
Original Medicare does not cover an annual routine physical exam.
“Routine physical exams”
The exception. Medicare covers a one-time 'Welcome to Medicare' preventive visit in your first 12 months on Part B, and a yearly Wellness Visit after that. These are NOT physicals — they review your health risks and build a prevention plan; the doctor does not examine you the way a physical would.
42 CFR 411.15(a)(1); Medicare Benefit Policy Manual Ch. 16 §90 · Medicare.gov — What's not covered · checked 2026-10-02
Part D does not cover drugs used for cosmetic purposes or to promote hair growth.
“Agents when used for cosmetic purposes or hair growth”
The exception. A Part D plan may choose to cover an excluded drug as a supplemental drug under enhanced alternative coverage — the manual says a sponsor “may only include coverage of drugs that would meet the definition of a Part D drug but for the application of section 20.1” as a supplemental benefit. Where a plan does, the drug sits outside the standard benefit: it does not count toward your out-of-pocket threshold.
Medicare Prescription Drug Benefit Manual Ch. 6 §20.1 (exception: §20.3) · checked 2026-10-04
Part D does not cover drugs when they are used to treat sexual or erectile dysfunction.
“Agents when used for the treatment of sexual or erectile dysfunction”
The exception. A Part D plan may choose to cover an excluded drug as a supplemental drug under enhanced alternative coverage — the manual says a sponsor “may only include coverage of drugs that would meet the definition of a Part D drug but for the application of section 20.1” as a supplemental benefit. Where a plan does, the drug sits outside the standard benefit: it does not count toward your out-of-pocket threshold. The exclusion follows the use; the same drug prescribed for another accepted indication is not excluded on this ground.
Medicare Prescription Drug Benefit Manual Ch. 6 §20.1 (exception: §20.3) · checked 2026-10-04
Part D does not cover drugs used only to relieve the symptoms of a cough or cold.
“Agents when used for the symptomatic relief of cough and colds”
The exception. A Part D plan may choose to cover an excluded drug as a supplemental drug under enhanced alternative coverage — the manual says a sponsor “may only include coverage of drugs that would meet the definition of a Part D drug but for the application of section 20.1” as a supplemental benefit. Where a plan does, the drug sits outside the standard benefit: it does not count toward your out-of-pocket threshold.
Medicare Prescription Drug Benefit Manual Ch. 6 §20.1 (exception: §20.3) · checked 2026-10-04
Part D does not cover drugs when they are used for weight loss or weight gain — the exclusion that keeps most weight-loss GLP-1 prescriptions off the formulary.
“Agents when used for anorexia, weight loss, or weight gain”
The exception. A Part D plan may choose to cover an excluded drug as a supplemental drug under enhanced alternative coverage — the manual says a sponsor “may only include coverage of drugs that would meet the definition of a Part D drug but for the application of section 20.1” as a supplemental benefit. Where a plan does, the drug sits outside the standard benefit: it does not count toward your out-of-pocket threshold. The exclusion follows the use, not the molecule: the same drug can be covered when it is prescribed for a different medically accepted indication.
Medicare Prescription Drug Benefit Manual Ch. 6 §20.1 (exception: §20.3) · checked 2026-10-04
Part D does not cover drugs when they are used to promote fertility.
“Agents when used to promote fertility”
The exception. A Part D plan may choose to cover an excluded drug as a supplemental drug under enhanced alternative coverage — the manual says a sponsor “may only include coverage of drugs that would meet the definition of a Part D drug but for the application of section 20.1” as a supplemental benefit. Where a plan does, the drug sits outside the standard benefit: it does not count toward your out-of-pocket threshold.
Medicare Prescription Drug Benefit Manual Ch. 6 §20.1 (exception: §20.3) · checked 2026-10-04
Prescription vitamin and mineral products are excluded from Part D.
“Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations”
The exception. A Part D plan may choose to cover an excluded drug as a supplemental drug under enhanced alternative coverage — the manual says a sponsor “may only include coverage of drugs that would meet the definition of a Part D drug but for the application of section 20.1” as a supplemental benefit. Where a plan does, the drug sits outside the standard benefit: it does not count toward your out-of-pocket threshold. Prenatal vitamins and fluoride preparations are named exceptions and remain covered.
Medicare Prescription Drug Benefit Manual Ch. 6 §20.1 (exception: §20.3) · checked 2026-10-04
Drugs you can buy without a prescription are excluded from Part D, even when a doctor tells you to take one.
“Nonprescription drugs”
The exception. A Part D plan may choose to cover an excluded drug as a supplemental drug under enhanced alternative coverage — the manual says a sponsor “may only include coverage of drugs that would meet the definition of a Part D drug but for the application of section 20.1” as a supplemental benefit. Where a plan does, the drug sits outside the standard benefit: it does not count toward your out-of-pocket threshold.
Medicare Prescription Drug Benefit Manual Ch. 6 §20.1 (exception: §20.3) · checked 2026-10-04