Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reduce the cost-share and provide reimbursement for the eye exam (92004) and 
eye refraction (92015) provided on July 22, 2021. 
 
You asked the Plan to reduce the cost-share and provide reimbursement for the eye exam and refraction. You 
say that this was a medical eye exam for your drusen, and you were told that you had the beginnings of macular 
degeneration during this exam and received a prescription for the condition. You were told this should have 
been coded as a medical exam as you had a medical exam and a separate refraction for your eyeglass 
prescription on the same date. The Plan denied your request. The Plan says that the provider in this case is not 
part of your routine (non-medical) vision vendor network, and therefore the Plan cannot pay more than $75 for 
the eye exam and refraction. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $30 copayment for each specialist office visit for 
diagnosis and treatment of diseases and injuries of the eye. The Plans contract also says that there is a $75 
allowance for routine eye exam services when received from a provider who does not participate in the Plans 
specified routine vision vendor network. 
 
The Plan says you must pay the full cost over and above the Plans $75 routine vision allowance for the eye 
exam and refraction. Based on the Plan contract, however, you cannot be asked to pay more than a $30 copayment for the medical eye exam. The Current Procedural Terminology (CPT) Code Manual Definition of 
Code 92004 is ophthalmological services: medical examination and evaluation with initiation of diagnostic and 
treatment program; comprehensive, new patient, 1 or more visits. The claim provided does include listed 
medical diagnoses, and the Plan did not request or receive a copy of medical records from this visit to show 
that the services provided were fully routine. The record also indicates that the provider in this case is part of 
the Plans medical network, but is not part of the Plans routine vision vendor network. Based on this 
information, we decided that the Plan has to process this service under your medical benefits and reduce your 
responsibility for the eye exam (92004) provided on July 22, 2021, to $30, and must provide additional 
reimbursement as you have already paid the provider. 
 
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 eye refractions and routine eye exams received from 
providers who do not participate in the Plans specified routine vision vendor network up to $75.  
 
The record shows that the charges for the eye refraction, which was billed with a routine diagnosis and 
performed by a provider outside of the Plans routine vision vendor network, total $55. The Plan did not 
request medical records to dispute that this service was purely routine in nature. The full cost of the eye 
refraction is covered by the Plans routine vision allowance. This portion of the claim should remain processed 
by the Plans vision carrier and should show $0 enrollee liability. Therefore, we decided that the Plan has to 
reduce the cost-share and provide reimbursement for the eye exam (92004) and eye refraction (92015) provided 
on July 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.