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.  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).  For beneficiaries with pseudophakia, coverage is limited to one pair of eyeglasses or contact lenses after each cataract surgery with insertion of an IOL. Replacement frames, eyeglass lenses and contact lenses are noncovered. If a beneficiary has a cataract extraction with IOL insertion in one eye, subsequently has a cataract extraction with IOL insertion in the other eye, and does not receive eyeglasses or contact lenses between the two surgical procedures, Medicare covers only one pair of eyeglasses or contact lenses after the second surgery. If a beneficiary has a pair of eyeglasses, has a cataract extraction with IOL insertion, and receives only new lenses but not new frames after the surgery, the benefit would not cover new frames at a later date (unless it follows subsequent cataract extraction in the other eye).  Only standard frames (V2020) are covered. Additional charges for deluxe frames (V2025) will be denied as noncovered. When billing claims for deluxe frames, use code V2020 for the cost of standard frames and a second line item using code V2025 for the difference between the charges for the deluxe frames and the standard frames.  Tinted lenses (V2745), including photochromatic lenses (V2744), used as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic beneficiary, will be denied as noncovered. Scratch resistant coating (V2760), mirror coating (V2761), polarization (V2762), deluxe lens feature (V2702) and progressive lenses (V2781) will be denied as noncovered. You can find this information in Policy Article A52499 - Refractive Lenses.   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).  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 states that eyewear (post cataract surgery) is covered with a $0 copayment. 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). In addition, the Plan offers a supplemental (extra) benefit to cover routine vision services which are not covered by Original Medicare. This benefit includes a $300 allowance toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider once per calendar year. You can find this information on pages 81-82 and 85-86 of the Plan's 2021 Evidence of Coverage.