Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery or dental medicine (within the limitations in C.), doctor of podiatric medicine (within the limitations in D.), or doctor of optometry (within the limitations of F.), or a chiropractor (within the limits of G.), legally authorized to practice by a State in which the individual performs this function. The services performed by a physician within these definitions are subject to any limitations imposed by the State on the scope of practice. In all States, the issuance by the State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine. If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, such local standards will be issued in determining whether a particular physician has legal authorization. If State licensing law limits the scope of practice of a particular type of medical practitioner, only the services within these limitations will be covered.
The term “physician” does not include such practitioners as a Christian Science practitioner, or naturopath.
The requirement that a doctor of medicine must be legally authorized to practice medicine and surgery by the State in which the individual performs services is met where a physician is licensed by the State to practice medicine and surgery. A doctor of osteopathy who is legally authorized to practice medicine and surgery by the State in which the individuals performs services qualifies as a physician. In addition, a licensed osteopath or osteopathic practitioner qualifies as a “physician” to the extent that the individual performs services within the scope of the practice as defined by State law. For example, in some States osteopaths and osteopathic practitioners are limited in their practice to the manipulation of bones and muscles; such legally authorized services are covered.
A dentist is a “physician” under the health insurance program if the individual is a doctor of dental surgery or dental medicine legally authorized to practice dentistry by the State in which the individual performs services. However, a dentist is a physician only with respect to surgery related to the jaw or any structure contiguous to the jaw, or the reduction of any fracture of the jaw or any facial bone. In general, “the jaw or any structure contiguous to the jaw” includes structures of the facial area below the eyes; e.g., mandible, teeth, gums, tongue, palate, salivary glands, sinuses, etc. Because of the general exclusion of payment for dental services, payment for the services of dentists is also limited to those surgical procedures which are not primarily provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth. The coverage or exclusion of any given dental service is not affected by the professional designation of the “physician” rendering the service; i.e., an excluded dental service remains excluded and a covered dental service is still covered whether furnished by a dentist or a doctor of medicine. Effective with admissions on or after 1/1/73, the 1972 Amendments authorize the dentist caring for the patient to certify (without corroborating certification by a physician) that because of the patient's underlying medical condition and clinical status, the patient requires hospitalization for performance of excluded dental procedures.
for making the required physician certification and recertifications of the medical necessity for Part A and Part B provider services;