Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the lenses (V2203) and anti-reflective coating (V2750). We decided that the Plan does not have to pay for the progressive lenses (V2781) and high index materials (V2782).

You asked the Plan to pay for the eyeglasses. You say that these eyeglasses were medically necessary following your cataract surgery and should be covered in full by your medical benefits. The Plan denied your request. The Plan says that they have agreed to cover the standard frames (V2020); however, the anti-reflective coating (V2750), progressive lenses (V2781) and high index material (V2782) upgrades are not covered by Medicare. In addition, the lenses (V2203) were billed incorrectly and must be submitted with each lens on a separate line with the appropriate modifiers.

The Plan must follow Medicare rules. Medicare can cover one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and modifiers. A contract provider is an agent of the Plan. Services and referrals given by a contract provider are considered approved by the Plan unless notice is provided that the services will not be covered. The Plan follows these rules.

We decided that the Plan has to hold you harmless for the lenses (V2203) and anti-reflective coating (V2750).

In this case, the lenses (V2203) were inappropriately billed on the same line rather than as two separate line items with separate LT/RT modifiers. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line with 2 units of service, will be rejected as incorrect coding.

Anti-reflective coating (V2750) may be covered by Medicare in instances where an enrollee has monocular vision and the service is billed with the appropriate KX modifier. Documentation of medical necessity must be supplied to support the item as billed. In this case no provider statement or documentation of medical necessity were provided. However, there is also no documentation that the provider who furnished the eyeglasses, and who is contracted with the Plan, informed you that the anti-reflective coating is not a covered service in this case.

The file does not show that the Plan (or Plan-contracted provider, as an agent of the Plan) gave notice that the anti-reflective coating would not be covered. Under Medicare rules, this means that the anti-reflective coating is considered approved by the Plan. Additionally, you cannot be held liable for a payment denial that is based on a billing error submitted by a Plan-contracted provider. These services would not normally be covered by the Plan as currently billed, and the Plan does not have to pay for these services. However, in this instance we found that you cannot be held responsible for these charges either. Therefore, we decided that the Plan has to hold you harmless for the lenses (V2203) and the anti-reflective coating (V2750) provided on March 22, 2021.

We also decided that the Plan does not have to pay for the progressive lenses (V2781) and high index materials (V2782).

For Medicare-covered eyewear, high index materials (such as V2782) and progressive lenses (V2781) will be denied as non-covered services. There are no instances where these services may be covered by Original Medicare. While the Plan does offer a supplemental benefit to cover additional routine services which includes some upgrades, these services may only be applied to routine eyewear and must be supplied by a provider in the Plan's specified routine vision network. The rules for coverage under the Plan's supplemental benefit have also not been met in this case. Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781) and high index materials (V2782) provided on March 22, 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.