Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for determination of refractive state (92015),
ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic
and treatment program; comprehensive, established patient, 1 or more visits (92014) and scanning
computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or
bilateral; optic nerve (92133) provided on March 10, 2020.
You asked the Plan to waive the cost-share for the eyewear. You say that the services should be covered. The
Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
The ophthalmological office visit has been paid. The Plan paid $0.00 and you have a responsibility of $121.83,
$118.82 toward the deductible and a $3.01 copay. A review has been completed and it has been determined that
the ophthalmological office visit was processed correctly. You had $118.82 remaining towards your $225.00
deductible, which was applied on this claim and the deductible is now met. The Plan processes claims based on
the Medical allowable amount. The Medicare allowable for this services was determined to be $121.83. After
$118.82 was applied towards the deductible, $3.01 remained to be applied as the copay instead of the full
$30.00, making the correct member responsibility $121.83.
The glaucoma screening has been paid. The Plan paid $36.00 and you have a responsibility of $0.00. A review
has been completed and it has been determined that the glaucoma screening was processed correctly.
According to pages 83 and 84 of your 2020 EOC, you are responsible for a $0.00 copayment for a glaucoma
screening provided by a participating provider. This glaucoma screening processed correctly leaving no
member responsibility.
The eye refraction denied because Medicare does not provide coverage for eye refractions. However, your
supplemental vision plan covers eye refractions. The refraction service has been submitted to your
supplemental vision plan, and they paid $40.00 and you have a responsibility of $0.00. According to pages 96
and 97 of the 2020 EOC, you are responsible for a $0.00 copayment for a routine eye exam including refraction
provided by a participating provider. This refraction reprocessed correctly leaving no member responsibility.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the cost-share for determination of refractive state (92015), ophthalmological
services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment
program; comprehensive, established patient, 1 or more visits (92014) and scanning computerized ophthalmic
diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
(92133) provided on March 10, 2020.