---
kind: "section"
citation: "42 C.F.R. § 414.5"
title: "42"
number: "414.5"
heading: "Hospital services paid under Medicare Part B when a Part A hospital inpatient claim is denied because the inpatient admission was not reasonable and necessary, but hospital outpatient services would have been reasonable and necessary in treating the beneficiary."
url: "https://uscodex.org/cfr/42/414.5"
---

# §414.5. Hospital services paid under Medicare Part B when a Part A hospital inpatient claim is denied because the inpatient admission was not reasonable and necessary, but hospital outpatient services would have been reasonable and necessary in treating the beneficiary.

- (a) If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under [§ 482.30(d)](/cfr/42/482.30.md?p=d) of this chapter or [§ 485.641](/cfr/42/485.641.md) of this chapter after a beneficiary is discharged that the beneficiary's inpatient admission was not reasonable and necessary, the hospital may be paid for any of the following Part B inpatient services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, provided the beneficiary is enrolled in Medicare Part B:
  - (1) Services described in [§ 419.21(a)](/cfr/42/419.21.md?p=a) of this chapter that do not require an outpatient status.
  - (2) **Physical therapy services, speech-language pathology services, and occupational therapy services.**
  - (3) Ambulance services, as described in section 1861(v)(1)(U) of the Act, or, if applicable, the fee schedule established under [section 1834(l)](/cfr/42/1834.md?p=l) of Act.
  - (4) Except as provided in [§ 419.2(b)(11)](/cfr/42/419.2.md?p=b-11) of this chapter, prosthetic devices, prosthetics, prosthetic supplies, and orthotic devices.
  - (5) Except as provided in [§ 419.2(b)(10)](/cfr/42/419.2.md?p=b-10) of this chapter, durable medical equipment supplied by the hospital for the patient to take home.
  - (6) **Clinical diagnostic laboratory services.**
  - (7)
    - (i) Effective December 8, 2003, screening mammography services; and
    - (ii) **Effective January 1, 2005, diagnostic mammography services.**
  - (8) Effective January 1, 2011, annual wellness visit providing personalized prevention plan services as defined in [§ 410.15](/cfr/42/410.15.md) of this chapter.
- (b) If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under [§ 482.30(d)](/cfr/42/482.30.md?p=d) of this chapter or [§ 485.641](/cfr/42/485.641.md) of this chapter after a beneficiary is discharged that the beneficiary's inpatient admission was not reasonable and necessary, the hospital may be paid for hospital outpatient services described in [§ 412.2(c)(5)](/cfr/42/412.2.md?p=c-5), [§ 412.405](/cfr/42/412.405.md), [§ 412.540](/cfr/42/412.540.md), or [§ 412.604(f)](/cfr/42/412.604.md?p=f) of this chapter or [§ 413.40(c)(2)](/cfr/42/413.40.md?p=c-2) of this chapter that are furnished to the beneficiary prior to the point of inpatient admission (that is, the inpatient admission order).
- (c) The claims for the Part B services filed under the circumstances described in this section must be filed in accordance with the time limits for filing claims specified in [§ 424.44(a)](/cfr/42/424.44.md?p=a) of this chapter.

## Notes

### Amendments

[78 FR 50968, Aug. 19, 2013]

### Authority

Authority: 42 U.S.C. 1302, 1395hh, and 1395rr(b)(l).

### Source

Source: 55 FR 23441, June 8, 1990, unless otherwise noted.

### Amendments

[78 FR 50968, Aug. 19, 2013]