Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay a 70 percent coinsurance for the eye exam (92014). We decided that the 
Plan does not have to pay for the eye refraction (92015), bifocal lenses (V2203), and anti-reflective coating 
(V2750).  
 
You asked the Plan to pay for the eye exam (92014), eye refraction (92015), bifocal lenses (V2203), and anti-
reflective coating (V2750) provided on February 8, 2022 by an out-of-network (OON) provider. You say that 
the enrollee was going to this eye doctor's office before they moved, and was not aware they were OON. The 
Plan says that these services were rendered by a provider who is not in the Plan's network, and the benefit plan 
does not cover the eye exam and refraction. The Plan says that the enrollee's maximum benefit for the bifocal 
lenses and anti-reflective coating has been exceeded. 
 
We decided that the Plan has to pay a 70 percent coinsurance for the eye exam (92014).  
 
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. 
 
We looked at the file and the Plan's rules. The contract says you are responsible for a 30 percent coinsurance 
for Medicare covered vision services that are received out-of-network. The record shows that you received a 
medical eye exam from an out-of-network provider, in which the 30 percent coinsurance would apply. Based 
on this information, we decided that the Plan's rules for coverage of the eye exam have been met. Therefore, we 
decided that the Plan has to pay a 70 percent coinsurance for the eye exam (92014).  
 
We also decided that the Plan does not have to pay for the eye refraction (92015), bifocal lenses (V2203), 
and anti-reflective coating (V2750). 
 
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 refraction when it is billed as part of a routine eye exam, and you have a $200 
benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of Punctate keratitis, bilateral. The documentation also shows that the Plan paid $200 toward the 
glasses you received on February 8, 2022, and you are responsible for any remaining amount. Based on this 
information, we decided that the Plan's rules for coverage of the eye refraction, bifocal lenses, and anti-
reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction (92015), bifocal lenses (V2203), and anti-reflective coating (V2750). 
 
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.