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 Medicare-covered eyeglasses, only standard lenses and frames are covered. 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. 
 
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. 
Claim lines for anti-reflective coating (V2750), tints (V2744, V2745), oversized lenses (V2780) or 
polycarbonate or Trivex TM lenses (V2784) billed without a KX, GA, GY or GZ modifier will be rejected as 
missing information. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Local Coverage Article 
(LCA): Refractive Lenses  Policy Article (A52499). 
  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 
covers one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens. If you have two separate cataract operations, you cannot reserve the benefit 
after the first surgery and purchase two eyeglasses after the second surgery. 
 
The Plan also offers a supplemental (extra) benefit to cover routine vision services that are not covered by 
Original Medicare. This benefit includes one routine eye exam and up to $200 toward the cost of eyeglasses or 
contact lenses every year. After Plan-paid benefits for eyeglasses (lenses and frames) or contact lenses, you are 
responsible for the remaining cost. You can find this information on pages 102-103 of the Plan's 2022 Evidence 
of Coverage.