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Coverage criteria policies

Vision therapy / orthoptics and pleoptics - Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific 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.

Administrative Process

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

Prior authorization is required for more than 12 office visits for Vision Therapy / Orthoptics. Documentation of progress must be submitted along with a treatment plan indicating a plan toward a home program.

Coverage

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. Home visual therapy is to be used, including home treatment with patching, lens fogging, red/green/polaroid filters, and other lenses/devices.

The physician monitoring progress may bill for a limited examination in addition to the orthoptic/pleoptic training. Document in the medical record the physician saw the member and performed the necessary procedures for a limited examination. Examinations to evaluate visual therapy are limited to one per week.

Indications that are covered
  1. Diagnosis and treatment of amblyopia, sensory or motor strabismus, and accommodative disorders, including convergence insufficiency, causing subjective visual complaints which are not relieved by wearing prescription eyewear.
  2. Visual therapy for amblyopia is limited to children under age 10. If improvement is not noted after four sessions, the member must be referred to an appropriate professional (e.g., neurologist or ophthalmologist) for further evaluation.
Indications that are not covered
  1. Vision therapy for learning disabilities, including dyslexia.
  2. Vision therapy for any diagnosis other than those listed above as covered
  3. Vision therapy beyond the initial 12 visits where there is no evidence of progress toward a home program.

Definitions

Accommodative disorders are problems focusing the eyes

Amblyopia also known as “lazy eye”, is a vision development disorder in which an eye fails to achieve normal visual acuity, even with prescription eyeglasses or contact lenses

Convergence insufficiency is characterized by an outward turning of the eye that is present only at near or greater than distance fixation.

Orthoptics is the study and management of eye movement disorders and associated vision problems.

Strabismus is a failure of the two eyes to maintain proper alignment and work together

Vision therapy is a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the doctor to develop, rehabilitate and enhance visual skills and processing. http://www.aoa.org/Documents/optometrists/QI/definition-of-optometric-vision-therapy.pdf

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 codes

Codes

Description

92065

Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

97110

Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97112

Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

97530

Therapeutic activities, direct (one-on- one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

ICD-10-CM codes

Codes

Description

H49.00

Third [oculomotor] nerve palsy, unspecified eye

H49.01

Third [oculomotor] nerve palsy, right eye

H49.02

Third [oculomotor] nerve palsy, left eye

H49.03

Third [oculomotor] nerve palsy, bilateral

H49.10

Fourth [trochlear] nerve palsy, unspecified eye

H49.11

Fourth [trochlear] nerve palsy, right eye

H49.12

Fourth [trochlear] nerve palsy, left eye

H49.13

Fourth [trochlear] nerve palsy, bilateral

H49.20

Sixth [abducent] nerve palsy, unspecified eye

H49.21

Sixth [abducent] nerve palsy, right eye

H49.22

Sixth [abducent] nerve palsy, left eye

H49.23

Sixth [abducent] nerve palsy, bilateral

H49.30

Total (external) ophthalmoplegia, unspecified eye

H49.31

Total (external) ophthalmoplegia, right eye

H49.32

Total (external) ophthalmoplegia, left eye

H49.33

Total (external) ophthalmoplegia, bilateral

H49.40

Progressive external ophthalmoplegia, unspecified eye

H49.41

Progressive external ophthalmoplegia, right eye

H49.42

Progressive external ophthalmoplegia, left eye

H49.43

Progressive external ophthalmoplegia, bilateral

H49.881

Other paralytic strabismus, right eye

H49.882

Other paralytic strabismus, left eye

H49.883

Other paralytic strabismus, bilateral

H49.889

Other paralytic strabismus, unspecified eye

H49.9

Unspecified paralytic strabismus

H50.00

Unspecified esotropia

H50.011

Monocular esotropia, right eye

H50.012

Monocular esotropia, left eye

H50.021

Monocular esotropia with A pattern, right eye

H50.022

Monocular esotropia with A pattern, left eye

H50.031

Monocular esotropia with V pattern, right eye

H50.032

Monocular esotropia with V pattern, left eye

H50.041

Monocular esotropia with other noncomitancies, right eye

H50.042

Monocular esotropia with other noncomitancies, left eye

H50.05

Alternating esotropia

H50.06

Alternating esotropia with A pattern

H50.07

Alternating esotropia with V pattern

H50.08

Alternating esotropia with other noncomitancies

H50.10

Unspecified exotropia

H50.111

Monocular exotropia, right eye

H50.112

Monocular exotropia, left eye

H50.121

Monocular exotropia with A pattern, right eye

H50.122

Monocular exotropia with A pattern, left eye

H50.131

Monocular exotropia with V pattern, right eye

H50.132

Monocular exotropia with V pattern, left eye

H50.141

Monocular exotropia with other noncomitancies, right eye

H50.142

Monocular exotropia with other noncomitancies, left eye

H50.15

Alternating exotropia

H50.16

Alternating exotropia with A pattern

H50.17

Alternating exotropia with V pattern

H50.18

Alternating exotropia with other noncomitancies

H50.21

Vertical strabismus, right eye

H50.22

Vertical strabismus, left eye

H50.311

Intermittent monocular esotropia, right eye

H50.312

Intermittent monocular esotropia, left eye

H50.32

Intermittent alternating esotropia

H50.331

Intermittent monocular exotropia, right eye

H50.332

Intermittent monocular exotropia, left eye

H50.34

Intermittent alternating exotropia

H50.40

Unspecified heterotropia

H50.43

Accommodative component in esotropia

H50.60

Mechanical strabismus, unspecified

H50.611

Brown's sheath syndrome, right eye

H50.612

Brown's sheath syndrome, left eye

H50.69

Other mechanical strabismus

H50.89

Other specified strabismus

H50.9

Unspecified strabismus

H51.11

Convergence insufficiency

H53.001

Unspecified amblyopia, right eye

H53.002

Unspecified amblyopia, left eye

H53.003

Unspecified amblyopia, bilateral

H53.009

Unspecified amblyopia, unspecified eye

H53.011

Deprivation amblyopia, right eye

H53.012

Deprivation amblyopia, left eye

H53.013

Deprivation amblyopia, bilateral

H53.019

Deprivation amblyopia, unspecified eye

H53.021

Refractive amblyopia, right eye

H53.022

Refractive amblyopia, left eye

H53.023

Refractive amblyopia, bilateral

H53.029

Refractive amblyopia, unspecified eye

H53.031

Strabismic amblyopia, right eye

H53.032

Strabismic amblyopia, left eye

H53.033

Strabismic amblyopia, bilateral

H53.039

Strabismic amblyopia, unspecified eye

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.

References

  1. Information for this policy was taken from http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_008954

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Policy activity

  • 11/30/2015 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 07/2017

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