Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a contact lens fitting provided on January 14, 2021.

You asked the Plan to pay for eyewear fitting. You say that you do not understand why this key component of your eye exam is not covered. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the Plan has not received the primary payer Explanation of Benefits for this claim.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a routine eye examination as well as an allowance for contact lenses and the fitting of contact lenses.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has denied this claim on the basis that they did not receive the primary payer Explanation of Benefits (EOB) for this claim. However, the Plan has not identified a primary payer for you, nor has the Plan demonstrated that they fulfilled their obligation to coordinate benefits with your primary insurance carrier in any way even if one were to be identified. This contact lens fitting is covered by the Plan's routine vision care benefits up to a $300 benefit allowance. The billed amount of this contact lens fitting is $200, and the Plan has not shown that any previous amount had been applied to your eyewear benefit allowance, therefore the Plan has not shown that your eyewear benefit allowance had been exhausted. This service was provided by an in-network provider. Therefore, the Plan has not shown that its decision to deny payment for this service is correct or justified based on Medicare rules or your contract with the Plan. Therefore, we decided that the Plan has to pay for a contact lens fitting provided on January 14, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.