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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). 
 
PROSE (BostonSight, Needham, MA) devices are designed to rest on the sclera or white part of the eye and are 
used to treat ocular surface diseases, including some types of "dry eye." For Medicare billing purposes correct 
Healthcare Common Procedure Coding System (HCPCS) coding for this item is determined based upon the 
condition(s) being treated. When the PROSE device is used as a treatment for either of the following 
indications listed below, the correct HCPCS code to use is V2627 (Scleral cover shell): treatment of an eye 
rendered sightless and shrunken by inflammatory disease; or treatment of "dry eye" where the PROSE device 
serves as a substitute for the function of the diseased lacrimal gland. 
 
When the PROSE device is used for any conditions other than those listed above, the device must be coded 
with HCPCS code V2531 (contact lens, scleral, gas permeable, per lens (for contact lens modification, see 92325)) and is subject to the Medicare refractive lens statutory coverage exclusion. You can find this 
information in the Centers for Medicare and Medicaid Services, Local Coverage Article (LCA): 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 Plan 
offers a supplemental (extra) benefit to cover routine vision services that are not covered by Original Medicare. 
This benefit covers one non-Medicare covered eye exam every 12 months and up to $200 once every 24 
months towards the cost of eyewear (contact lenses, prescription lenses and frames). You may see any licensed 
vision provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 
You pay the provider for services and submit an itemized billing statement showing proof of payment to the 
Plan. You can find this information on pages 38-40 of the Plan's 2021 Schedule of Cost Sharing.