Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $75 more for the progressive lens (V2781). We decided that the Plan does 
not have to pay for the polycarbonate or equal lens (V2784) and anti-reflective coating (V2750), or pay in full 
for the progressive lens (V2781).  
 
You asked the Plan to pay for the polycarbonate or equal lens (V2784) and anti-reflective coating (V2750), and 
to pay more for the progressive lens (V2781) provided on April 11, 2022. You say that your benefits summary 
states that progressive lenses are covered in full. You also say that you believe you should be reimbursed for 
the cost of the progressive lenses, as it states in the benefits summary. The Plan says that polycarbonate or 
equal lens and anti-reflective coating are not covered benefits. 
 
We decided that the Plan has to pay $75 more for the progressive lens (V2781).  
 
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 contract says standard lenses that are covered in full include Tier I (standard) progressive 
lenses. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that you purchased progressive lenses. 
The contract clearly states that progressive lenses are covered in full, and you have a $200 allowance toward 
your purchase of frames and standard lenses. The provided documentation does not show that your $200 
allowance has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the 
progressive lens (V2781) have been met. Therefore, we decided that the Plan has to pay $75 more for the 
progressive lens (V2781).  
 
We also decided that the Plan does not have to pay for the polycarbonate or equal lens (V2784) and anti-
reflective coating (V2750), or pay in full for the progressive lens (V2781). 
 
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 contract says standard lenses that are covered in full include single vision, lined bifocal, 
lined trifocal, lenticular, and Tier I (standard) progressive lenses. 
 
We looked at the file and the Plan's rules. The record shows that you received enhanced lenses which are not 
covered by the Plan. We have also told the Plan they must pay $75 more for the progressive lenses, which has 
exhausted your eyewear allowance. Based on this information, we decided that the Plan's rules for coverage of 
the polycarbonate or equal lens, anti-reflective coating, and progressive lens have not been met. Therefore, we 
decided that the Plan does not have to pay for the polycarbonate or equal lens (V2784) and anti-reflective 
coating (V2750), or pay in full for the progressive lens (V2781). 
 
  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.