I don’t have a specific statutory or regulatory cite, but the transmittals cited in the Note (R1755CP and R101NCD) provide background information regarding the identification of the three specific surgical events that have been determined to be “serious, largely preventable, and of concern to both the public and health care providers,” as well as the specific coverage rules that apply to these three events (R1755CP).

Presumably, CMS’ authority for identifying these three events as non-covered arises under their general authority to determine what services are covered under Medicare. The primary coverage requirement established under Medicare law is that services be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. (See §1862(a)(1)(A) of the Social Security Act). It would be difficult to make the argument that the never events meet this threshold coverage requirement.

Judith

Thanks