Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the eye exam with photos and to pay $80 more for the frames and lens 
package. We decided that the Plan does not have to pay more than an additional $80 for the frames and lens 
package.  
 
You asked the Plan to pay for the eye exam with photos (92250) and to pay more for the frames and lens 
package provided on September 12, 2022. You say that the treating provider's name and practice is on the list 
of approved providers. The Plan says that the eye exam with photos (92250) is not covered by the Plan. The 
Plan also says the charges exceed the allowable rate for the frames and lens package. 
 
We decided that the Plan has to pay for the eye exam with photos and to pay $80 more for the frames 
and lens package.  
 
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 $300 toward the purchase and fitting of eyeglasses and pair of lenses or contact 
lenses per calendar year. The rules also 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. 
 
We looked at the file and the Plan's rules. The Explanation of Benefits that was submitted with this case shows 
the Plan only paid $220 for the frames and lens package. Based on this information, we decided that the Plan's 
rules for coverage of the eye exam with photos and the frames and lens package have been met, and the Plan 
must pay an additional $80 for the frames and lens package. The Plan has also not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request for the eye 
exam with photos. Specifically, the Plan denied this eye exam with photos (92250) saying it is not a covered 
service. We find that this service is a Medicare-covered outpatient diagnostic test, and the Plan has not 
supported their denial of payment in this case. Therefore, we decided that the Plan has to pay for the eye exam 
with photos and to pay $80 more for the frames and lens package.  
 
We also decided that the Plan does not have to pay more than an additional $80 for the frames and lens 
package. 
 
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 $300 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. Specifically, we have told the Plan they must pay $80 more for these 
services, and your maximum eyewear benefit of $300 will have been reached with this additional payment. 
Based on this information, we decided that the Plan's rules for coverage to pay more than a total of $300 for the 
frames and lens package have not been met. Therefore, we decided that the Plan does not have to pay more 
than an additional $80 for the frames and lens package. 
 
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.