Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    The term “vision therapy” has been used to describe a wide variety of treatments, including Pleoptic therapy to improve vision, Orthoptic therapy to improve Vergence, and other therapies designed to improve behavioral problems.

2)    Most QualChoice plans do not cover vision therapy. Refer to your Certificate of Coverage, Evidence of Coverage, or Summary Plan Description.

3)    Vision therapy developmental testing is covered once per lifetime.

4)    Convergence insufficiency is a binocular vision disorder in the ability for the eyes to turn inward towards each other.  Vision therapy has been evaluated for treatment of this disorder, and may offer benefits to some children with convergence insufficiency.  In those plans that cover vision therapy, Orthoptic training is covered on a limited basis for children with documented convergence insufficiency and requires prior authorization.

5)    Vision therapy used to treat nonspecific symptoms such as headaches and fatigue, juvenile delinquency, behavioral problems or poor learning, is not covered. None of these claims have been adequately supported by scientific evidence. 

Eye training exercises are not considered to be appropriately described by physical therapy codes.  As noted in BI307, physical therapy codes are only appropriately billed by MD, DOs, DCs, licensed physical therapists and licensed physical therapy assistants.

Vision therapy developmental testing is Medically Necessary once per lifetime. CPT code 96111 is appropriately used to describe developmental testing.  A separate detailed written report is required.

Sensorimotor exam with multiple measurements of ocular deviation (CPT code 92060) is covered for members under the age of 19, once per life time with any diagnosis. Additional exams are covered annually if preauthorized for members undergoing Orthoptic training.

Orthoptic training (CPT code 92065) is covered for members under the age of 19, up to two visits per year for convergence insufficiency or amblyopia. Prior authorization is required.  Additional treatments after one year will only be authorized if sensorimotor examination demonstrates objective improvement.

Codes Used In This BI:

92060             Sensorimotor examination with multiple measurements of ocular deviation

92065             Orthoptic and/or Pleoptic training, with continuing medical direction and                              evaluation

96111               Developmental testing, with interpretation and report. (Code deleted and replaced w/96112, 96113 eff 1-1-19)

96112               Developmental test admin (incl assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care prof, w/interpretation and report; first hour (Eff 1-1-19)

96113             Each additional 30 minutes (List separately in addition to code for primary procedure) (Eff 1-1-19)

Orthoptic are exercises designed to improve the function of the eye muscles. These exercises are considered particularly useful in the treatment of strabismus (cross-eyes). Pleoptic are exercises designed to improve impaired vision when there is no evidence of organic eye diseases.

While there is some evidence that vision therapy may provide some benefit in patients with neurological impairment, there has been little critical evaluation of these techniques.  There is also difficulty in assessing the literature because of variation in definitions and methods.  A remote near point of convergence is generally considered diagnostic of convergence insufficiency, but there is little consensus on what constitutes a normal near point.  Symptoms thought to be caused by convergence insufficiency (headache, eye strain) are subjective and difficult to quantify. 

In 2010, the American Optometric Association revised a guideline (originally produced in 1998) on accommodative and Vergence dysfunction.  This guideline recommends vision therapy for various dysfunctions of Vergence, and states that such treatment is beneficial for Asthenopia (eye strain).  However, the guideline does not detail its sources of evidence, its rating of evidence, or other attributes expected in an evidence-based guideline.  Further, this document only speaks of improving Vergence, without addressing clinically important outcomes.

The American Academy of Pediatrics in 1998 stated: “Learning disabilities are common conditions in pediatric patients. The etiology of these difficulties is multifactorial, reflecting genetic influences and abnormalities of brain structure and function. Early recognition and referral to qualified educational professionals is critical for the best possible outcome. Visual problems are rarely responsible for learning difficulties. No scientific evidence exists for the efficacy of eye exercises (“vision therapy”) or the use of special tinted lenses in the remediation of these complex pediatric developmental and neurologic conditions.”

Scheiman et al, in a pilot study reported in 2005, concluded vision therapy/Orthoptic was more effective than pencil push-ups or placebo vision therapy/Orthoptic in reducing symptoms and improving signs of convergence insufficiency in children 9-18 yrs of age.  This study enrolled only 47 children in three treatment groups but only 38 were included in the final analysis.  This study was designed as a pilot study to prepare the CITT Study Group for a large scale randomized clinical trial.  

 “Based on an assessment of claims and a study of published data, the consensus of ophthalmologists regarding visual training is that, except for near point of convergence exercises, visual training lacks documented evidence of effectiveness." (Helveston, 2005)

The widely reported Convergence Insufficiency Treatment Trial randomized 221 children aged 9-17 to four treatment groups:  home based pencil push-ups, home-based computer therapy and pencil push-ups, office based therapy with home reinforcement, or office based placebo therapy with home reinforcement.  The office based therapy group showed improved near point of convergence and reduced symptoms compared to the other groups at 12 weeks, and this improvement was sustained for one year.  However, the office based therapy group may well have benefited from specific home reinforcement not provided to the other groups, and the intensity of the office based program far surpassed that of the home based Orthoptic program.

The Convergence Insufficiency Treatment Study (NCT01515943) was reported in 2016.   Due to difficulty with recruitment and retention, the study investigators concluded “estimates of success are not precise and comparisons across groups are difficult to interpret.”

Dusek evaluated base prism reading glasses or computer training compared to placebo in 134 children, and found the best results to be from prismatic correction.  In this group, there was sustained improvement in reading time even when not wearing corrective lenses, suggesting that use of appropriate spectacles results in longer term improvement.  This is also one of the few studies to use patient oriented objective outcomes that matter.

1)     American Academy of Pediatrics, Committee on children with disabilities, AAP, AAO, AAPOS.(1998) Learning disabilities, dyslexia, and vision: a subject review. Pediatrics, 1998; 102:1217-1219.

2)     American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus and American Association of Certified Orthoptists.(2009) Joint Statement-Learning Disabilities, Dyslexia, and Vision. Pediatrics 2009; 124;837-844.

3)     American Optometric Association Consensus Panel on Care of the Patient with Accommodative or Vergence Dysfunction, 2010.   Accessed through Clinical Key 6 May 2013.

4)     Barrett BT.  A critical evaluation of the evidence supporting the practice of Behavioural vision therapy.  Ophthalmic Physiol Opt. Jan 2009; 29(1):4-25

5)     Dusek WA, Pierscionek BK, McClelland JF.  An Evaluation of Clinical Treatment of Convergence Insufficiency for children with reading difficulties.  BMC Ophthalmol.  2011:11(21)

6)     Helveston EM.(2005) Visual training: current status in ophthalmology. Am J Ophthal 2005; 140:903-10.

7)     Lavrich JB.  Convergence insufficiency and its current treatment.  Curr Op Ophthal 2010; 21(356-360)

8)     Scheiman M, Mitchell GL, et al.(2005) A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol, 2005; 123:14-24.

 

9)     Scheiman M, Mitchell GL, et al.(2008) The convergence insufficiency treatment trial: design, methods, and baseline data. Ophthalmic Epidemiol, 2008; 15:24-36.

This policy applies to all QualChoice Health Plans, unless there is indication otherwise or a stated exclusion.  Consult individual plan sponsor Summary Plan Description (SPD) for self-insured plans.  In the event of a discrepancy between this policy and a self-insured customer’s SPD, the SPD will prevail.  State and federal mandates will be followed as they apply.