Coverage criteria policies

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Prior authorization is not required for the initial twelve (12) office visits for Vision Therapy / Orthoptics.

Up to twelve (12) vision therapy / orthoptic treatment visits in the office to establish a home program are covered per the indications listed below and per your plan documents.

Indications that are covered

• Treatment of convergence insufficiency.
• Prisms, lenses, and filters necessary to complete the home program are covered under Durable Medical Equipment benefits.

Indications that are not covered

• Vision therapy / orthoptic office visits for any diagnosis other than convergence insufficiency are not covered because they are considered experimental/investigational.
• Vision therapy/orthoptic office visits exceeding 12 visits are considered not medically necessary. Published clinical studies show that a limited number of office visits, usually less than twelve, are required for resolution of convergence insufficiency. Office visits are only necessary to help establish or support a home program.
• Educational materials, including, but not limited to, computer software and workbooks.(code 99071).
• Corrective lenses (eyeglasses) for ongoing use.
• Vision restoration therapy is considered experimental and investigational for all indications because its effectiveness has not been validated in well-designed prospective clinical studies.

Convergence Insufficiency is the inability to maintain binocular function (keeping the two eyes working together) while working at a near distance. Typically, one eye will turn outward (intermittent exotropia) when focusing on a word or object at near. American Association for Pediatric Ophthalmology and Strabismus

Vision therapy is a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by a doctor to develop, rehabilitate and enhance visual skills and processing. American Optometric Association

Vision restoration therapy (VRT) is a home-based program that targets the vision center of the brain and is intended to improve visual function in patients with visual field deficits that may result from stroke or TBI. Patients employs a computer screen to focus on a displayed central point and respond every time they see light stimuli appear.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Medical Director Committee Approval 07/01/96; Revised 04/10/03, 1/14/08, 11/30/2015, 6/21/16; Annual Review 06/01/06, 8/1/07, 1/14/08, 9/9/09, 5/19/10, 5/2011, 5/2012, 5/2013, 5/2014, 5/2015, 1/2016, 7/2016, 7/2017

References

1. Hayes, Inc.- Health Technology Brief-Vision Therapy for Convergence Insufficiency and Accommodative Dysfunction in Children, Lansdale, PA: Hayes, Inc. Dec 2013, updated Nov 2015, Archived: Jan 17, 2017
2. Hayes, Inc. Directory-Vision Therapy for Dyslexia and Other Reading and Learning Disabilities. Lansdale, PA: Hayes, Inc July 2012, updated June 2015, May 2016
3. Hayes, Inc. Directory-Vision Therapy for Accommodative and Vergence Dysfunction, Nov 2011, May 2015, Archived: Dec 29, 2016.
4. American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Joint statement--Learning disabilities, dyslexia, and vision. Pediatrics. 2009 Aug;124(2):837-44. Reaffirmed 2014. Accessed May 2016. Available at URL address: http://www.aao.org/clinical-statement/joint-statement-learning-disabilities-dyslexia-vis
5. Scheiman M, Cotter S, Kulp MT, et al.; Convergence Insufficiency Treatment Trial Study Group. Treatment of accommodative dysfunction in children: results from a randomized clinical trial. Optom Vis Sci. 2011;88(11):1343-1352.
6. Scheiman M, Cotter S, Mitchell GL, et al.; Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008;126(10):1336-1349.
7. Scheiman M, Kulp M, Cotter S, et al.; Convergence Insufficiency Treatment Trial Study Group. Long-term effectiveness of treatments for symptomatic convergence insufficiency in children. Optom Vis Sci. 2009;86(9):1096-1103.
8. Shin HS, Park SC, Maples WC. Effectiveness of vision therapy for convergence dysfunctions and long-term stability after vision therapy. Ophthalmic Physiol Opt. 2011;31(2):180-189.