---
kind: "section"
citation: "42 C.F.R. § 411.404"
title: "42"
number: "411.404"
heading: "Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary."
url: "https://uscodex.org/cfr/42/411.404"
---

# §411.404. Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.

- (a) **Basic rule.** A beneficiary who receives services that constitute custodial care under [§ 411.15(g)](/cfr/42/411.15.md?p=g) or that are not reasonable and necessary under [§ 411.15(k)](/cfr/42/411.15.md?p=k), is considered to have known that the services were not covered if the criteria of paragraphs [(b)](#b) and [(c)](#c) of this section are met.
- (b) **Written notice.**
  - (1) Written notice is given to the beneficiary, or to someone acting on his or her behalf, that the services were not covered because they did not meet Medicare coverage guidelines.
  - (2) A notice concerning similar or reasonably comparable services furnished on a previous occasion also meets this criterion.
  - (3) After a beneficiary is notified that there is no Medicare payment for a service that is not covered by Medicare, he or she is presumed to know that there is no Medicare payment for any form of subsequent treatment for the non-covered condition.
- (c) **Source of notice.** The notice was given by one of the following:
  - (1) **The QIO, intermediary, or carrier.**
  - (2) The group or committee responsible for utilization review for the provider that furnished the services.
  - (3) **The provider, practitioner, or supplier that furnished the service.**

## Notes

### Amendments

[54 FR 41734, Oct. 11, 1989, as amended at 69 FR 66423, Nov. 15, 2004]

### Authority

Authority: 42 U.S.C. 1302, 1395w-101 through 1395w-152, 1395hh, and 1395nn.

### Source

Source: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.

### Amendments

[54 FR 41734, Oct. 11, 1989, as amended at 69 FR 66423, Nov. 15, 2004]