ABN_Rfx Cat Sx_Pretesting with attach

A. Notifier: Ophthalmic Consultant of New York, PLLC. 21-04 30th Avenue, Astoria NY 11103.

B. Patient Name

C. Patient Date of Birth

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare doesn't pay for the items or services below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the items or services below.

D. Items or Services

Prophylactic screening tests for the Eyehance lens

Refractive tests for the Eyehance lens

E. Reason Medicare May Not Pay: Ancillary diagnostic tests of both eyes for refractive errors including low-order and higher- order optical aberrations (i.e., myopia, hyperopia, astigmatism, defocus, coma, trefoil, etc using: refractometry, wavefront aberrometry, and corneal topography. (CPT 92015, 92025)

The Medicare Benefit Policy Manual Chapter 16 §90 states:eye refractions by whatever practitioner and for whatever purpose performed are not coveredExpenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage.

Prophylactic screening of both eyes for potential disorders or diseases using one or more tests such as: SCODI-A, SCODI-P, or pachymetry. (CPT 92132, 92133, 92134, 76514)

The Medicare law, Social Security Act 1862(a1) (A), does not cover any service that is not required by medical necessity " for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

F. Estimated Cost: $500

Read this notice, so you can make an informed decision about your care.

Ask us any questions you may have after you finish reading.

Choose an option below about whether to receive the Prophylactic screening and refractive tests listed above.

Note: If you choose Option 1 or 2, we may help you to use any other

insurance that you might have, but Medicare cannot require us to do this.

Check only one box. We cannot choose a box for you.

OPTION 1. I want the items or services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.OPTION 2. I want the items or services listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment, and I cannot appeal if Medicare is not billed.OPTION 3. I don’t want the items or services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227 / TTY: 1-877-486-2048 Signing below means that you have received and understand this notice. You also receive a copy.

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Form Approved OMB No. 0938-0566

Pre-surgical testing for Eyehance Lens