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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 state that the correction of common refractive errors by eyeglasses, contact lenses or other prosthetic 
devices is specifically excluded from coverage. The use of radial keratotomy and/or keratoplasty for the 
purpose of refractive error compensation is considered a substitute or alternative to eyeglasses or contact 
lenses, which are specifically excluded by Section 1862(a)(7) of the Act (except in certain cases in connection 
with cataract surgery). In addition, many in the medical community consider such procedures cosmetic surgery, 
which is excluded by section Section1862(a)(10) of the Act. Therefore, radial keratotomy and keratoplasty to 
treat refractive defects are not covered. You can find this information in National Coverage Determination 
(NCD): Refractive Keratoplasty (80.7). 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator N means that this is a non-covered service. 
These codes are carried on the Healthcare Common Procedure Coding System (HCPCS) tape as noncovered 
services. There will be no payment amounts for these codes and no separate payment is ever made. When these 
services are covered, payment for them is subsumed by the payment for the services to which they are incident. 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
The rules say that a contract plan provider is an agent of the plan. Services and referrals obtained from a plan 
provider are viewed as plan-approved unless notice is given that the services will not be covered. When a plan 
provider gives, or refers an enrollee for, a service that the enrollee reasonably believes is covered by the plan, 
the enrollee is held harmless and need not pay more than the plan-allowed cost-sharing for that service.  
 
If a service is never covered by the plan and the plan's Evidence of Coverage (EOC) is clear that the service or 
item is never covered, the plan does not have to hold the enrollee harmless.  
 For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone 
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-16, Medicare Managed Care Manual, Chapter 4, Section 160. 
 
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.