Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay a larger amount for the cataract surgery (66821) and eyeglasses 
(V2750, V2020, V2799) provided on November 29, 2022, and January 23, 2023. 
 
You asked the Plan to pay a larger amount for the cataract surgery and eyeglasses. You say that you were told 
that the copayments for your cataract surgery would be $275 each, and your contract states that you will be 
able to receive eyeglasses following these procedures at no cost to you. The Plan denied your request. The Plan 
says this cost sharing was charged correctly. 
 
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 $300 
copayment for outpatient surgery or procedures performed in a network outpatient hospital setting, and there is 
coverage for one pair of standard Medicare-covered eyeglasses or contact lenses following cataract surgery 
which includes insertion of an intraocular lens. This benefit requires a $0 copayment from an in-network 
provider or 20% coinsurance from an out-of-network provider. Progressive lenses, no-line bifocal or trifocal 
lenses, tinting (except for certain ultraviolet-screening coatings), scratch resistant coatings, or oversized lenses 
are not covered unless required by Medicare guidelines. 
 
You have been asked to pay a $300 copayment for the cataract surgery. This service was provided in an in-
network outpatient hospital setting. The transcript of your call log with customer service on November 11, 
2022, shows that the customer service representative did state that this procedure would require a $275 
copayment at an ambulatory surgical center or a $300 copayment in an outpatient hospital setting. 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. 
 
In addition, the record shows that you paid $129.99 for progressive bifocal lenses, $64.99 for frames, $0.02 for 
a blue light filter and $3.12 in sales tax for a total of $198.12. The Plans allowed amount for these services 
(the Medicare-allowed price for these services) is $21.04 for the covered portion of the lenses and $64.99 for 
the frames. The cost of progressive lenses, blue light tinting and sales tax are not covered by Medicare as these 
services are not considered medically necessary as defined by Medicare. No reimbursement will be allowed for 
these services as they do not fall under the Medicare-defined standard Medicare-covered eyeglasses, which 
includes standard lenses and standard frames with no add-ons other than those few which are eligible and 
proven medically necessary.  
 
The Plan paid the full allowed $21.04 for the lenses and $51.99 for the frames for a total of $73.03. These 
services were purchased from an out-of-network provider, and the Plan has appropriately assessed 20% 
coinsurance for the frames. (The allowed cost of the frames is $64.99 x 20% coinsurance = $13.00 for your 
share of the cost of the frames). You are responsible for the cost of the non-covered services and your 
coinsurance for services from an out-of-network provider. These services were processed correctly based on 
your contract with the Plan. 
 
Therefore, we decided that the Plan does not have to pay a larger amount for the cataract surgery (66821) and 
eyeglasses (V2750, V2020, V2799) provided on November 29, 2022, and January 23, 2023.