Appeal type: unknown
Decision: unknown

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. 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Medicare Managed Care Manual, Chapter 1, Section 20.2. 
 
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 sales taxes where appropriate were included in the calculation of reasonable charges 
computed. They were also accounted for in the calculation of the base fee schedules for DME and 
orthotic/prosthetic devices. The Consumer Price Index used to update fee schedules also accounts for sales tax. 
Therefore, MACs do not make any additional payment for sales taxes and do not make adjustments in fees to 
reflect local changes in tax rates. You can find this rule in the Medicare Claim Processing Manual, chp. 23- Fee 
Schedule Administration and Coding, 80.3.1- Calculating Customer Charge (Rev.1,10-01-03, B3-5010.1, B3-
5213. 
 
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 Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information in Chapter 3 on pages 3-4 to 3-6 
of the plan's 2019 Evidence of Coverage. 
 
 
 
 
The health plan contract says one (1) pair of eyeglasses or contact lenses after each cataract surgery that 
includes insertion of an intraocular lens (additional pairs of eyeglasses or contacts are not covered by 
Medicare). If you have two separate cataract operations, you cannot reserve the benefit after the first surgery 
and purchase two eyeglasses after the second surgery. Covered eyeglasses after cataract surgery includes 
standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, 
deluxe frames, tinting, progressive lenses or anti-reflective coating). You can find this information in Chapter 4 
on page 4-48 of the plan's 2019 Evidence of Coverage.