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)

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.