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Vision therapy involves a range of optometric treatment modalities, including lenses, prisms, filters, occlusion, and other materials, methods, equipment, and procedures, including eye exercises and behavioral modalities that are used for eye movement and fixation training. The therapeutic goal of vision therapy is to correct or improve specific visual dysfunctions, such as amblyopia, strabismus, and accommodative and convergence disorders, as well as reading disorders such as dyslexia that purportedly are related to lack of eye coordination.

Orthoptic and vision training may utilize vectograms, stereoscopes, synoptophores, or other devices to present visual stimuli, typically line or contour targets, binocularly. Vectograms, polarized slides that are viewed through polarized filters, are used to dissociate the eyes and train vergence skills, i.e., the task of the patient is to visually fuse the two figures. A stereoscope is an optical instrument with two eyepieces that produces two horizontally separated images of the same object to provide a single image with an appearance of depth, i.e., three dimensions. Stereoscopes can be used to train fusional vergences in nonstrabismic cases. Synoptophores are modified stereoscopes that may be used to develop the vergence system in cases of strabismic and nonstrabismic anomalies of binocular vision (Cooper, 1988). Traditional vision training techniques require a doctor or technician to interpret the patient’s responses and to use the information to change stimulus conditions in order to improve binocular response. Moreover, clinicians may change targets at different speeds and instruct or motivate patients differently. These factors all contribute to a lack of standardization and unreliability of traditional methods. More recent developments using computerized orthoptics permit standardization of orthoptic testing and therapy, improve reliability, and improve patient motivation, particularly in the young or noncommunicative patient. These newer, automated vision-training techniques use microprocessor anaglyph stimuli, i.e., random dot stereograms (RDS), in an operant conditioning paradigm to make rapid, almost instantaneous changes in stimulus parameters and to provide immediate feedback of reinforcement. Biofeedback techniques using infrared eye position monitoring and auditory signals to indicate correct or incorrect eye positioning also have been used (van Brocklin et al., 1981; Cooper, 1988).

The specific techniques, duration of training, and scheduling and timing of therapy vary widely from program to program. While advocates of vision therapy emphasize the need to individualize treatment, this lack of standardization makes it difficult to draw inferences about the effectiveness of treatment (AOA, 1988).

Vision therapy that involves occlusion administered as treatment for amblyopia is medically necessary.

Vision therapy that involves prism adaptation prior to surgery administered as treatment for acquired esotropia is medically necessary.

Office-based vergence/accommodative therapy may be considered medically necessary for patients with symptomatic convergence insufficiency if, following a minimum of 12-weeks of home-based therapy (e.g., push-up exercises using an accommodative target; push-up exercises with additional baseout prisms; jump to near convergence exercises; stereogram convergence exercises; recession from a target; and maintaining convergence for 30-40 seconds), symptoms have failed to improve.

Vision therapy that involves orthoptics or prisms administered as treatment for amblyopia, or orthoptics, occlusion, or prisms as treatment for strabismus, intermittent exotropia, and accommodative deficiencies such as accommodative insufficiency and infacility is considered investigational.

Vision therapy administered as treatment for divergence excess exotropia and convergence excess is considered investigational.

Vision therapy and orthoptics, including but not limited to the use of colored lenses and filters, base-in prisms, or occlusion, administered for educational purposes as treatment for dyslexia and other learning and reading disabilities is considered investigational.

None

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

3/10/2004: Code Reference section updated

4/9/2009: Policy reviewed, no changes

04/25/2011: Policy statement revised to add a new medically necessary statement for convergence insufficiency. Policy statement regarding learning disabilities changed from investigational to not medically necessary. Added ICD-9 code 378.83 to the Covered codes table.

03/02/2012: Policy reviewed. Deleted outdated references from the Sources section. 

04/04/2013: Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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