DESCRIPTION
NOTE: This policy addresses office-based orthoptic training and does not address standard vision therapy with lenses, prisms, filters or occlusion.
Orthoptic training includes a wide range of nonsurgical optometric treatment modalities. Modalities include eye exercises, flashing light response exercises, prisms, wearing tinted or colored lenses, filters, occluders, specialized instruments, computer programs and other devices intended to improve eye movements and/or visual tracking.
Convergence insufficiency is a binocular vision disorder in which the eyes turn inward towards each other. Symptoms of this common condition may include eyestrain, headaches, blurred vision, diplopia, sleepiness, difficulty concentrating, movement of print, and loss of comprehension after short periods of reading or performing close activities. Prism reading glasses, home therapy with pencil push-ups, office-based vision therapy and orthoptics have been evaluated for the treatment of convergence insufficiency.
Some learning disabilities, particularly those in which reading is impaired, have been associated with deficits in eye movements and/or visual tracking. For example, many dyslexic persons may have unstable binocular vision and report that letters may appear to move around, causing visual confusion. Currently, orthoptic training is being investigated for treatment of attention deficient disorders, dyslexia, dysphasia, and reading disorders.
Orthoptic training is also known as vision training, visual therapy, optometric vision therapy, orthoptics - eye exercises, orthoptic vision therapy, and syntonic optometry.
POLICY
Office-based orthoptic training for the treatment of symptomatic convergence insufficiency is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Orthoptic eye exercises for the treatment of learning disabilities is considered not medically necessary.
Orthoptic eye exercises for all other conditions/diseases, including but not limited to: visual disorders other than convergence insufficiency is investigational.
MEDICAL APPROPRIATENESS
Office-based orthoptic training for the treatment of symptomatic convergence insufficiency is considered medically appropriate if ALL of the following criteria are met:
Documentation submitted shows that the individuals symptoms failed to improve with at least a 12 week home-based orthoptic training session (e.g., pencil push-up exercises using an accommodative target; push-up exercises with additional base-out prisms; jump to near convergence exercises; stereogram convergence exercises; recession from a target; and maintaining convergence for 30-40 seconds)
Individual is 9 to 17 years of age
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Up to 12 sessions of office-based therapy, typically performed once a week, has been shown to improve symptomatic convergence insufficiency (CI) in children aged 9 to 17 years.
There is insufficient evidence in published studies to state whether orthoptic training for the treatment of vision or learning disabilities other than symptomatic convergence insufficiency is effective.
SOURCES
American Academy of Ophthalmology. (2009). Policy statement: Learning disabilities, dyslexia, and vision. Retrieved April 26, 2011 from http://www.aao.org/about/policy/upload/learning-disabilities-dyslexia-vision-2009.pdf.
American Academy of Optometry and the American Optometric Association. (1999). Vision therapy. Information for health care and other allied professionals. A joint organizational policy statement of the American Academy of Optometry and the American Optometric Association. Retrieved April 26, 2011 from http://www.aoa.org/documents/JOPS%20on%20Vision%20Therapy.pdf.
American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus & American Association of Certified Orthoptists. (2009). Joint statement - Learning disabilities, dyslexia, and vision. Pediatrics, 124 (2), 837-844.
American Optometric Association. (2006). Care of the patient with accommodative and vergence dysfunction. Retrieved April 26, 2011 from http://www.aoa.org/documents/CPG-18.pdf.
American Optometric Association. (2008). Care of the patient with learning related vision problems. Retrieved April 26, 2011 from http://www.aoa.org/documents/CPG-20.pdf.
Bharadwai, S. R., & Candy, T. R. (2009). Accommodative and vergence responses to conflicting blur and disparity stimuli during development. Journal of Vision, 9 (11), 1-18.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2011). Orthoptic for the treatment of learning disabilities (9.03.03). Retrieved April 26, 2011 from BlueWeb. (19 articles and/or guidelines reviewed)
Brautaset, R., & Jennings, A. J. (2006). Effects of orthoptic treatment on the CA/C and AC/A ratios in convergence insufficiency. Investigative Ophthalmology & Visual Science, 47 (7), 2876-2880.
Convergence Insufficiency Treatment Trial Investigator Group. (2008). The convergence insufficiency treatment trial: Design, methods, and baseline data. Ophthalmic Epidemiology, 15 (1), 24-36. (Level 2 Evidence - Independent study)
Convergence Insufficiency Treatment Trial Study Group. (2008). Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Archives of Ophthalmology, 126 (10), 1336-1349. (Level 2 Evidence - Independent study)
Convergence Insufficiency Treatment Trial Study Group. (2009). Long-term effectiveness of treatments for symptomatic convergence insufficiency in children. Optometry and Vision Science, 86 (9), 1096-1103. (Level 3 Evidence - Independent study)
Handler, S. M., Fierson, W. M., Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, et al. (2011). Joint technical report - Learning disabilities, dyslexia, and vision. Pediatrics, 127 (3), e818-e856.
Kulp, M., Mitchell, G. L., Borsting, E., Scheiman, M., Cotter, S., Rouse, M., et al. (2009). Effectiveness of placebo therapy for maintaining masking in a clinical trial of vergence/accommodative therapy. Investigative Ophthalmology & Visual Science, 50 (6), 2560-2566. (Level 3 Evidence - Independent study)
National Guideline Clearinghouse. (2009). Pediatric and vision examination. Retrieved August 13, 2010 from http://www.guidelines.gov.
Optometrists Network. (2010). What is convergence Insufficiency (CI)? Retrieved August 16, 2010 from http://www.convergenceinsufficiency.org/.
Optometrists Network. (2010). What is vision therapy? Retrieved August 16, 2010 from http://www.children-special-needs.org/vision_therapy/what_is_vision_therapy_pf.html.
Sander, T., Sprenger, A., Neumann, G., Machner, B., Gottschalk, S., Rambold, H., et al. (2009). Vergence deficits in patients with cerebellar lesions. Brain, 132 (Pt. 1), 103-115. (Level 3 Evidence - Independent study)
Scheiman, M., Rouse, M., Kulp, M. T., Cotter, S., Hertle, R., & Mitchell, G. L. (2009). Treatment of convergence insufficiency in childhood: A current perspective. Optometry and Vision Science, 86 (5), 420-428.
Yang, Q., Vernet, M. Orssaud, C., Bonfils, P., Londero, A., & Kapoula, Z. (2010). Central crosstalk for somatic tinnitus: Abnormal vergence eye movements. PloS One, 5 (7), e11845. (Level 4 Evidence - Independent study)
ORIGINAL EFFECTIVE DATE: 3/1/1994
MOST RECENT REVIEW DATE: 10/8/2011
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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