Eye Refraction: Statutory Denials

Published 02/08/2018

Denial Reason, Reason/Remark Code(s)
  • PR-204: This service/equipment/drug is not covered under the patient's current benefit plan
  • CPT code: 92015
  • Eye refraction is never covered by Medicare
  • The Centers for Medicare & Medicaid Services (CMS) does not require providers to submit claims for services that are excluded by statute under Section 1862(a) (1) of the Social Security Act. However, if the patient (or his/her representative) believes that a service may be covered and asks that a claim be submitted or desires a formal Medicare determination, you must file a claim for that service to effectuate the patient's right to a determination.
Notice of Exclusion from Medicare Benefits Notice
  • If you are submitting a non-covered service to Medicare for denial purposes, the service may be submitted with HCPCS modifier GY. This modifier lets us know that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit.
  • CMS has developed new Advance Beneficiary Notice (ABN) forms. The new forms incorporate the 'old' Notice of Exclusion from Medicare Benefits (NEMB) language. Use of the  revised ABN is optional for services that are excluded from Medicare benefits. Access the revised ABN, and other background information from the CMS website.
  • If you have obtained a valid ABN for excluded services, submit claims for this service with HCPCS modifier GY. Refer to the Palmetto GBA Modifier Lookup tool for information on HCPCS modifier GY. This tool is located under Self Service Tools on the Palmetto GBA Web page.

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