Vision test denied coverage

Have you talked with an attorney?

@JohnW14426 

Just guessing but it maybe the way that the claim is handled - and how it is being processed or required to be processed by your Humana (added) Vision coverage.

Medicare will ALWAYS deny 90215 because it is not covered under Medicare (and in turn, your Medicare Advantage plan).  

However, since you have this added coverage under the Medicare Advantage plan - Humana advantage plan. Mandatory Supplemental Vision Benefit VIS752 - then it seems that it has to be submitted separately to the insurer.

Since it is never covered under Medicare then there is no need for a denial from Medicare for your (eye) coverage to even be submitted to Medicare and the doc needs to submit it separately.  OR the doc has to submit it with the info asked for by Medicare (see below)

This is not always the case with special benefits of a added supplemental type that a beneficiary might have - many do require that the claim be denied by Medicare before it is processed by the whatever added coverage insurer.  Like my eye coverage - they do require a denial from Medicare for 92015 before they process this part of my coverage but it sounds like this is not the case with you Humana extended eye coversge.

Here’s the Medicare Contractor’s rule of claim coverage from the contractor that services my area - they should all be the same in this regards, I think.

Medicare Claims Processing - Optometry and Ophthalmology: Determination of Refractive State- published 05/29/2020 - (jurisdiction M Part B)

copied and pasted below:

Medicare statutorily excludes payment for determination of refractive state, CPT Code 92015. If the patient asks you to submit a claim for denial or for secondary insurance purposes, submit CPT code 92015 with HCPCS modifier GY. (HCPCS modifier GY indicates that the service is statutorily excluded from Medicare coverage.) If the patient does not need a Medicare denial for refraction then you are not required to submit a claim for an eye refraction. An eye refraction is never covered by Medicare.

This is written to the doc office for claims   submission - not you as the beneficiary.

So my advice here is ask Humana how the claim needs to be submitted for coverage without all the hassles it is causing you - BTW, if you have a Medicare. broker who wrote this Medicare policy for you - ask them because this should be something that they should be able to either answer or can find out for you.

I also found this:  THIS SEEMS TO FIT YOUR SITUATION 

HealthcareManagement Consultant:  04/21/2022. What to do when a Medicare Managed Care Plan changes rules on refraction

from this link: (copy & paste)

In January 2022, Humana notified participating providers in a letter that identified refraction services (CPT code 92015 Determination of Refractive State) are considered bundled into the vision codes (92002, 92004, 92012 and 92014) and not payable separately by Humana or the patient. For traditional Medicare, the determination of the refractive state which is necessary for obtaining glasses and includes specification of lens type (monofocal, bifocal, other) lens power, axis, prism, absorptive factor, impact resistance and other factors is considered self-pay (as are most glasses and contact lenses). Under Traditional Medicare the determination of refractive state is statutorily excluded from coverage and is considered self- pay for the patient. The Humana process appears to hold the patient harmless (not financial responsible) for these charges based on the use of the “bundling” process.

It goes on to say what the practice should do - 

There are directions  for this to opthalmologist all over the world wide web - here is another - just so you know.

American Acadamy of Opthalmology (SavyCoder) - Back to the Basics—Coding for Refractions Using CPT Code 92015 (Tip: Rules Vary!)

Yea, I am probably giving you more info than you need but just imagine how intelligent you are gonna sound to Humana or the Humana broker when you are asking the question about claims submission for this refraction service.

No need for an attorney - just a good broker that knows the product they are selling and keeps up with the changes.