Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 92014 and 92250. We 
decided that the Plan does not have to pay for the services described by procedure code(s) 92015.  
 You asked the Plan to pay for procedure codes 92014 and 92250 provided on July 27, 2023. You say that you 
would like the Plan to reconsider their denial of payment. The Plan says that procedure code 92014 denied 
correctly as diagnosis code Z01.01 can only be used as the Principal/First-Listed Diagnosis code on a claim. 
The Plan says that procedure code 92015 was already processed and paid. The Plan says that they are 
reprocessing the claim for procedure code 92250 with a member responsibility of $87.72 for this code. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 92014 and 92250.  
 
The Plan must follow Medicare rules. The rules 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan provided no Medicare billing criteria showing that the full 
diagnosis code, Z01.01, can only be paid if coded first. Per Medicare payment guidelines, diagnosis code 
Z01.01 only requires an additional code to identify abnormal findings and does not state that this code must be 
coded first. Additionally, the Plan says that they are reprocessing the claim for procedure code 92250 leaving 
you with a member responsibility of $87.72; however, the Plan has not provided enough evidence (paid claim) 
to determine if the correct member responsibility was applied to this code. Therefore, we decided that the Plan 
has to pay for the services described by procedure code(s) 92014 and 92250.  
 
We also decided that the Plan does not have to pay additionally for the services described by procedure 
code(s) 92015. 
 
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 $15 for out-of-network refraction exams (92014). 
 
We looked at the file and the Plan's rules. Your contract with the Plan clearly states you must pay for any 
amount over $15 for a refraction exam provided by an out-of-network provider. You are responsible for the 
remaining $45 dollars for code 92015. Based on this information, we decided that Medicare rules for coverage 
of the services described by procedure code(s) 92015 have not been met. Therefore, we decided that the Plan 
does not have to pay for the services described by procedure code(s) 92015. 
 
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.