Coverage for vision therapy is determined according to individual or group customer benefits. If the member has benefits for vision therapy, the following medical necessity and frequency guidelines apply.

Generally, positive results can be achieved with 3 to 12 consecutive months of treatment, at an average rate of two exercise sessions per week. Whether performed by a physician, optometrist, or physical therapist (when prescribed by a physician or optometrist), payment may be allowed for up to a maximum of two exercise sessions per week for one treatment period of six consecutive months. If the vision therapy exceeds the six-month limitation, documentation will be required to substantiate the medical necessity for further treatments.

Coverage is subject to any applicable physical medicine limitation in the individual or group member's benefit contract. If the member does not have benefits for physical medicine or has exhausted those benefits, vision therapy is not eligible. Participating, preferred, and network providers can bill the member for services exceeding the benefit maximum.

The most common diagnoses for which payment may be allowed are amblyopia, strabismus, accommodative dysfunction, and general binocular dysfunction.

Vision therapy for the treatment of learning disabilities (315.00-315.09, 315.1-315.2, V40.0), poor school test scores, and behavioral problems (309.3, 312.81, V40.3, V40.9) is not covered.

Claims involving any other diagnosis should be referred for a medical review.

Vision therapy performed to maintain a level of function is not covered. A participating, preferred, or network provider can bill the member for the denied service. A maintenance program consists of activities that preserve the patient's present level of function and/or prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur.

Home computer orthoptic programs consist of eye exercises done on a computer that can be tailored to an individual's personal binocular problem. These programs can be used alone or often are prescribed as a component of a vision therapy program that can be reinforced at home. Home computer orthoptic programs are not eligible for reimbursement as there are no direct professional services rendered with home use.

Description

Orthoptics and pleoptics are common forms of vision therapy. Orthoptics are exercises designed to improve the function of the eye muscles. These exercises are considered particularly useful in the treatment of strabismus (cross-eyes). Pleoptics are exercises designed to improve impaired vision when there is no evidence of organic eye diseases.

Coverage is subject to any applicable physical medicine limitation in the individual or group member's benefit contract.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

FEP covers nonsurgical treatment for amblyopia and strabismus, for children from birth through age 12.

PRN References

06/1997, Vision therapy