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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
Medicare does not pay for low vision aids. This exclusion includes all devices that use one or more lenses to
aid vision or magnify images. This rule applies no matter the size, form or technological features of the device.
This rule does not apply to:
1. post-surgical prosthetic lenses after surgery in which the lens of the eye was removed;
2. prosthetic intraocular lenses (IOLs) and one pair of conventional eyeglasses or contact lenses furnished after
each cataract surgery with insertion of an IOL; and
3. prosthetic lenses used by those who are lacking the natural lens of the eye and who were not furnished with
an IOL.
You can find this rule at 42 CFR Section 411.15(b).
Medicare does not pay for eye exams for the purpose of prescribing, fitting, or changing eyeglasses or contact
lenses for refractive error only. Medicare does not pay for procedures performed in the course of any eye exam
to determine the refractive state of the eyes. Refractive procedures are not covered even when done in
connection with otherwise covered diagnosis or treatment of illness or injury. You can find these rules at 42
CFR Section 411.15(c).
The rules say that the addition of UV coating (V2755) is not reasonable and necessary for polycarbonate lenses
(V2784). Claims for code V2755 billed in addition to code V2784 will be denied as not reasonable and
necessary. Additional information regarding the coding and billing of UV coating (V2755) on lenses with UV
protective properties inherent in the material may be found in the related Policy Article. Lenses made of
polycarbonate or other impact-resistant materials (V2784) are covered only for beneficiaries with functional
vision in only one eye. In this situation, an impact-resistant material is covered for both lenses, if eyeglasses are
covered. Claims for code V2784 that do not meet this coverage criterion will be denied as not reasonable and
necessary. Anti-reflective coating (V2750), tints (V2744, V2745) or oversize lenses (V2780) are covered only
when they are medically necessary for the individual beneficiary and the medical necessity is documented by
the treating practitioner. When these features are provided as a beneficiary preference item and are billed with
an EY modifier (see LCD-related Standard Documentation Requirements Article), they will be denied as not
reasonable and necessary. You can find this information in Medicare's Local Coverage Determination (LCD):
Refractive Lenses (L33793).
The rules say that use of polycarbonate or similar material (V2784) or high index glass or plastic (V2782,
V2783) for indications such as light weight or thinness will be denied as a noncovered deluxe feature.
Only standard frames (V2020) are covered. Additional charges for deluxe frames (V2025) will be denied as
noncovered.
Codes V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, V2110, V2111, V2112,
V2113, V2114, V2199, V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209,
V2210, V2211, V2212, V2213, V2214, V2299, V2300, V2301, V2302, V2303, V2304, V2305, V2306,
V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2399, V2410, V2430, V2499, V2700, and
V2770 describe specific eyeglass lenses. Only one of these codes may be billed for each lens provided. These
codes include both aspheric and nonaspheric lenses. Anti-reflective coating (V2750) is a clear lens treatment
used to decrease glare and internal/external reflections. For anti-reflective coating (V2750), tints (V2744,
V2745) or oversized lenses (V2780), if medical necessity is documented by the treating practitioner, the KX
modifier must be added to the code. For polycarbonate or Trivex TM lenses (V2784), if they are for a
beneficiary with monocular vision, the KX modifier must be added to the code. The KX modifier may only be
used when these requirements are met. When the KX modifier is billed, documentation to support the medical
necessity of the lens feature must be available upon request. You can find this information in Medicare's Local
Coverage Article: Refractive Lenses - Policy Article (A52499).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health
plan contract says that Original Medicare doesn't cover routine eye exams (eye refractions) for
eyeglasses/contacts. One (1) routine eye exam every year. The routine eye exam includes a glaucoma test for
people who are at risk for glaucoma and a retinal exam for diabetics. One (1) pair of prescription eyewear every
year. A maximum benefit of $100 every year for member's choice of the following: eyeglasses (frame and
lenses), or eyeglass lenses only or, eyeglass frames only or contact lenses instead of eyeglasses. Maximum plan
benefit coverage amount of $100 every year applies to the retail cost of frames and/or lenses (including any
lens options such as tints and coating). The maximum benefit amount must be used in a single visit. Medicarecovered
eyewear is not included in the supplemental (i.e., routine) benefit maximum. Note: You are responsible
for any costs above the $100 maximum for supplemental (i.e., routine) eyewear. You can find this information
in Chapter 4 on pages 123-124 of the plan's 2020 Evidence of Coverage.