Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reimburse you an additional amount for the medical eye exam. We decided 
that the Plan does not have to reimburse you an additional amount for the contact lenses, contact lens fitting, 
CT, ultrasound and refraction.  
 
You asked the Plan to reimburse you an additional amount for the contact lenses, contact lens fitting, computed 
tomography (CT), ophthalmic ultrasound, medical eye exam and refraction. You say that you would like 
reconsideration because you believe you should be reimbursed an additional amount for these services and 
supplies. The Plan says that these claims have processed correctly. 
 
We decided that the Plan has to reimburse you an additional amount for the medical eye exam.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
copay for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye. 
 
We looked at your request, the file and rules. Based on this information we have determined that criteria for 
coverage and additional reimbursement have been met. Specifically, the documentation submitted indicates 
that you received a medical eye exam. This is a covered benefit per your contract with the Plan.  
 
We also decided that the Plan does not have to reimburse you an additional amount for the contact 
lenses, contact lens fitting, CT, ultrasound and refraction. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for an ultrasound and a $200 copayment for a CT-Scan. 
 
You paid $78 for the CT and $39 for the ultrasound. This means you have paid less than your contracted 
amount with the Plan for these services. Therefore, we decided that the Plan does not have to reimburse you an 
additional amount for the CT or ultrasound. 
 
The Plan must follow Medicare rules. The rules say that refractive procedures are not covered even when done 
in connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at your request, the file and rules. Based on this information we determined that the Plan does not 
have to reimburse you an additional amount for the refraction. Specifically, the documentation submitted indicates that you received a medical eye exam. An eye refraction is not a covered benefit when provided as 
part as a Medicare-covered medical eye exam.  Therefore, we decided that the Plan does not have to reimburse 
you an additional amount for the refraction. 
 
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 up to $100 for contact lenses.  
 
We looked at your request, the file and Plan rules. Based on this information we determined that the contact 
lenses and lens fitting do not meet criteria for additional reimbursement. The record indicates that the Plan has 
reimbursed you $100 towards contact lenses. This benefit has been exhausted. Additionally, the lens fitting is 
not a covered benefit. Therefore, we decided that the Plan does not have to reimburse you an additional amount 
for the contact lenses or lens fitting. 
 
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.