Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reimburse for eyeglasses. We also decided that the Plan does not have to 
reimburse for an eye examination, contact lens evaluation, fundus photography, and an eye refraction.  
 
You asked the Plan to reimburse for an eye examination, contact lens evaluation, fundus photography, an eye 
refraction and eyeglasses provided from February 22, 2022, to June 28, 2023. You say you are assuming that 
your claims have been denied since you have not received reimbursement for any of your previously submitted 
receipts. You also say that it is your understanding that there is coverage for eye care with your Plan. The Plan 
says that the services were previously considered and denied for out-of-network, as well as you pay the 
deductible for these items or services. 
 
We decided that the Plan has to reimburse for the eyeglasses.  
 
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 rules state there is a $0 copayment for eyeglasses (lenses and frames). 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $0 copayment for eyeglasses (lenses 
and frames) when received out-of-network. The record shows that the deductible does not apply to eyeglasses 
(lenses and frames). Based on this information, we decided that the Plan's rules for coverage of an eye 
examination, contact lens evaluation, fundus photography, and an eye refraction have been met. Therefore, we 
decided that the Plan has to reimburse the deductible for eyeglasses.  
 
We also decided that the Plan does not have to reimburse for an eye examination, contact lens 
evaluation, fundus photography, and an eye 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 there is a $1000 deductible which applies to out-of-network, non-Medicare 
covered eye examination and additional services during the visit.  
 
 
  You asked the Plan to reimburse for an eye examination, contact lens evaluation, fundus photography, and an 
eye refraction, which fall under the deductible. Eye examinations, contact lens evaluations, fundus 
photography, and eye refractions fall within the out-of-network, non-Medicare covered eye examination and 
additional services during the visit benefit category. The Plan has followed Medicare rules by clearly disclosing 
in the contract that there is a $1000 deductible which applies to out-of-network, non-Medicare covered eye 
examination and additional services during the visit. This cost sharing is a contractual obligation that had not 
been met at the time an eye examination, contact lens evaluation, fundus photography, and an eye refraction 
was received on February 22, 2022, to June 28, 2022. Therefore, we decided that the Plan does not have to 
reimburse for an eye examination, contact lens evaluation, fundus photography, and an eye refraction. 
 
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.