Orthoptic Training for the Treatment of Vision or Learning Disabilities

POLICY NUMBER

L.9.03.407

DESCRIPTION

Convergence Insufficiency

Convergence insufficiency is a binocular vision disorder associated with defects in the eyes’ ability to turn inward toward each other (eg, when looking at near objects). The diagnosis of convergence insufficiency is made when individuals have a remote near point of convergence or difficulty in sustaining convergence in conjunction with sensations of visual or ocular discomfort at near vision. 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, and 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 individuals may have an unstable binocular vision and report that letters appear to move around, causing visual confusion.

TreatmentOrthoptic training refers to techniques designed to correct accommodative and convergence insufficiency (or convergence dysfunction), which may include push-up exercises using an accommodative target of letters, numbers, or pictures; push-up exercises with additional base-out prisms; jump-to-near convergence exercises; stereogram convergence exercises; and recession from a target. A related but distinct training technique is behavioral or perceptual vision therapy, in which eye movement and eye-hand coordination training techniques are used to improve learning efficiency by optimizing visual processing skills.

In addition to its use in the treatment of accommodative and convergence dysfunction, orthoptic training is being investigated for the treatment of attention deficit disorders, dyslexia, dysphasia, and reading disorders.

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).

POLICY

Orthoptic eye exercises for the treatment of learning disabilities are considered investigational.

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 individuals 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 base-out prisms; jump-to-near convergence exercises; stereogram convergence exercises; recession from a target; and maintaining convergence for 30 to 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.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

Up to 12 sessions of office-based vergence/accommodative therapy, typically performed once per week, has been shown to improve symptomatic convergence insufficiency in children aged 9 to 17 years. If patients remain symptomatic after 12 weeks of orthoptic training, alternative interventions should be considered.

A diagnosis of convergence insufficiency is based on asthenopic symptoms (sensations of visual or ocular discomfort) at near point combined with difficulty sustaining convergence.

Convergence insufficiency and stereoacuity is documented by:

• Exodeviation at near vision at least 4 prism diopters greater than at far vision; AND

• Insufficient positive fusional vergence at near (positive fusional vergence less than 15 prism diopters blur or break) on positive fusional vergence testing using a prism bar; AND

• Near point of convergence break of more than 6 cm; AND

• Appreciation by the patient of at least 500 seconds of arc on stereoacuity testing.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

3/2003: Approved by Medical Policy Advisory Committee (MPAC)

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.

03/19/2014: Policy reviewed; no changes.

12/31/2014: Code Reference section updated to revise the description of the following HCPCS code: V2799. 

08/31/2015: Code Reference section updated for ICD-10.

03/02/2016: Policy title changed from "Orthoptics for the Treatment of Learning Disabilities and Visual Dysfunctions" to "Orthoptic Training for the Treatment of Vision or Learning Disabilities." Policy description updated regarding convergence insufficiency and orthoptic training. Policy statements unchanged. Policy guidelines updated regarding office-based vergence/accommodative therapy and convergence insufficiency. Added medically necessary and investigative definitions.

06/09/2016: Policy number A.9.03.03 added.

03/29/2017: Policy reviewed; no changes.

04/10/2018: Policy description updated. Policy statements unchanged.

04/08/2019: Policy reviewed; no changes.

05/27/2021: Policy description updated to change "deficient" to "deficit." Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

12/15/2021: Code Reference section updated to revise code description for CPT code 92065, effective 01/01/2022.

05/19/2022: Policy reviewed. Policy section updated to change "not medically necessary" policy statement to "investigational." Policy statement intent unchanged.

12/20/2022: Code Reference section updated to add new CPT code 92066 and to revise the description for CPT code 92065, effective 01/01/2023.

07/10/2023: Policy reviewed. Policy statement updated to change "patients" to "individuals."

04/26/2024: Policy description updated to change "patients" to "individuals." Policy statements unchanged.

07/26/2024: Policy updated to change the medical policy number from "A.9.03.03" to "L.9.03.407."

SOURCE(S)

Blue Cross Blue Shield Association policy # 9.03.03

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy. 

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

Covered Codes

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