TL;DR
Chapter 16 of the Medicare Benefit Policy Manual lists the general exclusions from Medicare coverage: items and services Medicare does not pay for regardless of who furnishes them. It covers services that are not reasonable and necessary, care for which no one has a legal obligation to pay, services paid for by other government programs, care outside the United States, personal comfort items, routine services, hearing aids, custodial care, cosmetic surgery, dental services and services related to noncovered care.
Chapter 16 at a glance
- Current revision
- Rev. 13593
- Issued January 26, 2026
- Effective
- February 26, 2026
- Implemented April 27, 2026
- Sections
- 38
- 17 top-level sections
- Transmittals in history
- 10
- Listed at the end of the chapter
- Monthly searches
- 70
- Google Ads, US, October 2026
What chapter 16 governs for billing
Section 10 lists the statutory exclusions from section 1862(a) of the Social Security Act, and the rest of the chapter explains each one. The broadest is section 20: services that are not reasonable and necessary for the diagnosis or treatment of illness or injury. The others are categorical: routine foot care (30), services for which neither the beneficiary nor anyone else has a legal obligation to pay (40), services furnished, paid for or authorized by federal, state or local government entities, including VA and TRICARE situations (50), and services furnished outside the United States except in the limited circumstances the chapter describes (60).
Section 40 was revised in 2025 and 2026. It explains that the no-legal-obligation exclusion applies when items and services are furnished free of charge, such as free screenings, but that a provider waiving its charge for a particular person or group does not by itself bar Medicare payment for others; the subsections apply the rule to indigence, providers that bill only insured patients, other health coverage, warranties, members of religious orders, ambulance services and people in the custody of a penal authority.
Sections 80 to 180 cover the remaining categories: personal comfort items (80), routine physical checkups, eyeglasses and other routine services and appliances except where a specific benefit applies (90), hearing aids and certain auditory implants (100), custodial care (110), cosmetic surgery except to repair accidental injury or improve the function of a malformed body member (120), charges by immediate relatives or household members (130), dental services in connection with the care of teeth (140), services payable by automobile, no-fault, liability or workers' compensation insurance (150), and services related to and required because of noncovered care (180).
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 16 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 20 | Services Not Reasonable and Necessary | Services that are not reasonable and necessary, the most common exclusion on claims. |
| 40 | No Legal Obligation to Pay for or Provide Services | No legal obligation to pay, recently revised with new examples. |
| 40.7 | Individuals in Custody of a Penal Authority | Individuals in the custody of a penal authority. |
| 50.3 | Items or Services Paid for by Governmental Entity | Items or services paid for by a government entity. |
| 120 | Cosmetic Surgery | Cosmetic surgery and its exceptions. |
| 140 | Dental Services Exclusion | The dental services exclusion. |
| 180 | Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare | Services related to and required as a result of noncovered services. |
How chapter 16 shows up on claims and denials
Excluded services are denied as noncovered, usually with reason code 96 or 204, and the beneficiary is liable for statutorily excluded care whether or not an Advance Beneficiary Notice was given. Providers often report these lines with modifier GY so the claim adjudicates quickly, and some secondary insurers need the Medicare denial before they will pay.
Section 20 denials are different. A service denied as not reasonable and necessary falls under the limitation on liability in the Claims Processing Manual chapter 30, so the beneficiary can be billed only when a valid ABN was obtained before the service. When the exclusion depends on another payer, such as workers' compensation or a government program, the claim belongs to that payer and Medicare's secondary payer rules apply.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| 96 | Claim adjustment reason code | Non-covered charge for a statutorily excluded item or service. |
| 204 | Claim adjustment reason code | Service not covered under the patient's current benefit plan. |
| 50 | Claim adjustment reason code | Not reasonable and necessary under section 20. |
| N130 | Remark code | Consult plan benefit documents for restrictions on this service. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 13593, issued January 26, 2026, effective February 26, 2026, implemented April 27, 2026. That revision changed sections 40 (No Legal Obligation to Pay for or Provide Services), 40.7 (Individuals in Custody of a Penal Authority), 50.3.3 (Examples of Application of Government Entity Exclusion).
The newest rows of the transmittal history printed at the end of the chapter (10 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R198BP | November 6, 2014 | Medicare Coverage of Items and Services in Category A and B Investigational Device Exemption (IDE) Studies | 8921 |
| R189BP | June 27, 2014 | Invalidation of National Coverage Determination 140.3 - Transsexual Surgery | 8825 |
| R186BP | April 16, 2014 | Clarification to Pub. 100-02, Medicare Benefit Policy Manual Regarding Antigens and Deletion of Section 13.14 from Chapter 13 of Pub. 100-08, Medicare Program Integrity Manual | 8665 |
| R170BP | May 10, 2013 | Updates to Medicare Coverage of Hepatitis B Vaccine and its Administration and Medicare Coverage of the Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS) | 8275 |
| R102BP | February 12, 2009 | Shipboard Services Billed to the Carrier and Services Not Provided Within the United States | 6327 |
| R66BP | February 23, 2007 | Services Not Provided Within United States | 5427 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 40 | No Legal Obligation to Pay for or Provide Services | Rev. 13593, January 26, 2026; effective February 26, 2026 |
| 40.7 | Individuals in Custody of a Penal Authority | Rev. 13593, January 26, 2026; effective February 26, 2026 |
| 50.3.3 | Examples of Application of Government Entity Exclusion | Rev. 13593, January 26, 2026; effective February 26, 2026 |
| 10 | General Exclusions from Coverage | Rev. 198, November 6, 2014; effective January 1, 2015 |
| 180 | Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare | Rev. 189, June 27, 2014; effective May 30, 2014 |
| 90 | Routine Services and Appliances | Rev. 186, April 16, 2014 |
| 60 | Services Not Provided Within United States | Rev. 102, February 13, 2009 |
| 100 | Hearing Aids and Auditory Implants | Rev. 39, November 10, 2005; effective November 10, 2005 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
10 General Exclusions from Coverage · p. 3
20 Services Not Reasonable and Necessary · p. 3
30 Foot Care · p. 4
40 No Legal Obligation to Pay for or Provide Services · p. 4 · 7 subsections
- Open section 40 in the PDF
- 40.1 Indigence · p. 4
- 40.2 Provider, Physician, or Supplier Bills Only Insured Patients · p. 5
- 40.3 Medicare Patient Has Other Health Coverage · p. 5
- 40.4 Items Covered Under Warranty · p. 6
- 40.5 Members of Religious Orders · p. 7
- 40.6 Ambulance Services · p. 7
- 40.7 Individuals in Custody of a Penal Authority · p. 8
50 Items and Services Furnished, Paid for or Authorized by Governmental Entities - Federal, State, or Local Governments · p. 9 · 13 subsections
- Open section 50 in the PDF
- 50.1 Items and Services Which a Non-Federal Provider Furnishes Pursuant to an Authorization Issued by a Federal Agency · p. 10
- 50.1.1 Veterans' Administration (VA) Authorized Services · p. 10
- 50.1.2 Medicare Secondary Payment Where VA Authorizes Fewer Days Than Total Number of Covered Days in the Stay · p. 12
- 50.1.3 Effect of VA Payments on Medicare Deductible and Utilization · p. 13
- 50.1.4 VA "Fee Basis Card" · p. 13
- 50.1.5 Services Authorized by Indian Health Service · p. 18
- 50.2 Items and Services Furnished by Federal Provider of Services or Federal Agency · p. 18
- 50.3 Items or Services Paid for by Governmental Entity · p. 19
- 50.3.1 Application of Exclusion to State and Local Government Providers · p. 19
- 50.3.2 Application of Exclusion to Nongovernmental Providers, Physicians and Suppliers · p. 20
- 50.3.3 Examples of Application of Government Entity Exclusion · p. 20
- 50.4 TRICARE and CHAMPVA (Civilian Health and Medical Program of Veterans Administration) · p. 22
- 50.5 Active Duty Members of Uniformed Services · p. 24
60 Services Not Provided Within United States · p. 24
70 Services Resulting from War
80 Personal Comfort Items · p. 26
90 Routine Services and Appliances · p. 26
100 Hearing Aids and Auditory Implants · p. 28
110 Custodial Care · p. 29 · 1 subsections
- Open section 110 in the PDF
- 110.1 Custodial Care Under a Hospice Program · p. 30
120 Cosmetic Surgery · p. 30
130 Charges Imposed by Immediate Relatives of the Patient or Members of the Patient's Household · p. 30
140 Dental Services Exclusion · p. 32
150 Services Reimbursable Under Automobile, No Fault, Any Liability Insurance or Workers' Compensation · p. 33
170 Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider · p. 34
180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare · p. 35
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Benefit Policy Manual chapter 16
QuickAuth coordinates requirement checks, documentation, submission and status tracking with human review, so the coverage conditions in this chapter are looked at before the service. QuickRCM handles claim readiness and the coverage denials that follow.
Frequently asked questions: chapter 16
What does Medicare never cover?
Chapter 16 of the Medicare Benefit Policy Manual lists the general exclusions, including services that are not reasonable and necessary, routine physicals and foot care, hearing aids, custodial care, cosmetic surgery, most dental care, personal comfort items and services paid for by government programs.
Can a provider bill the patient for an excluded service without an ABN?
For services excluded by statute, yes: the beneficiary is liable without an ABN, although a voluntary notice is good practice. For services denied as not reasonable and necessary, a valid ABN is required before the beneficiary can be billed.
Is dental care excluded from Medicare?
Section 140 excludes services in connection with the care, treatment, filling, removal or replacement of teeth, with limited exceptions where the dental service is integral to a covered medical procedure.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Benefit Policy Manual, Chapter 16: General Exclusions From CoverageVersion Rev. 13593, issued 2026-01-26 · effective 2026-02-26 · file bp102c16.pdfSHA-256 5371c3cbbfcefb08…
- Medicare Benefit Policy Manual (Pub. 100-02)Version 17 chapter PDFs; newest revision Rev. 13889 (chapter 15), issued 2026-07-30 · effective 2026-09-27 · file 100-02-benefit-policy-manual/*.pdf (17 chapters; SHA-256 of their sha256sum listing)SHA-256 be35772e4f9f80b4…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.