Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the computerized corneal topography (92025). We decided that the 
Plan does not have to waive the copayment for the extracapsular cataract removal with insertion of intraocular 
lens and prosthesis (66982).  
 
You asked the Plan to pay for the computerized corneal topography (92025) and to waive the copayment for 
the extracapsular cataract removal with insertion of intraocular lens and prosthesis (66982) provided on April 
21, 2022, and May 4, 2022. You say that there is confusion due to two different opinions for the denial from 
April 21, 2022. You also say that you would like to know why you are being charged $250.00 for your share of 
the procedure on May 4, 2022, but on the same procedure for the same date you do not have a shared payment. 
The Plan says that the computerized corneal topography is not covered under your routine vision benefit. The 
Plan also says you are responsible for a $250 copay for the extracapsular cataract removal. 
 
We decided that the Plan has to pay for the computerized corneal topography (92025).  
 
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 has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the record shows that the Plan denied the computerized corneal 
topography as a non-covered service. We find this decision to be incorrect, as this service is a diagnostic 
imaging service, and the contract clearly states the Plan covers diagnostic services. There was no other reason 
or evidence provided to support the Plan's denial of this service. Therefore, we decided that the Plan has to pay 
for the computerized corneal topography (92025).  
 
We also decided that the Plan does not have to waive the copayment for the extracapsular cataract 
removal with insertion of intraocular lens and prosthesis (66982). 
 
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 $250 
copay for Outpatient hospital services.  
 
You have been asked to pay a $250 copay for the extracapsular cataract removal with insertion of intraocular 
lens and prosthesis (66982). This item/service falls within the Outpatient hospital services benefit category. 
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 copayment for the extracapsular cataract removal with insertion of 
intraocular lens and prosthesis (66982). 
 
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.