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Medical Policy: 09.03.02
Original Effective Date: March 1988
Reviewed: August 2011
Revised: March 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Orthoptics, also known as vision training or vision therapy, is intended to improve or correct diagnosed visual dysfunctions. Modalities include eye exercises, flashing light response exercises, prisms, wearing tinted or colored lenses, filters, occluders, specialized instruments, computer programs and other devices. Vision therapy is often requested for individuals with the following visual dysfunctions:
- Accommodative disorders-focusing problems
- Amblyopia-lazy eye
- Ocular motility dysfunction- eye movement disorders
- Strabismus-misalignment of the eyes
- Treatment of learning disabilities- particularly reading disorders including attention deficient disorder, dyslexia, dysphasia or other reading disorders
- Vergence dysfunction-insufficiency in using both eyes together or
- Visual rehabilitation after traumatic brain injury or stroke
Tinted lenses have been widely publicized as a successful new treatment for reading disorders and visual stress in children. Helen Irlen identified a syndrome defined as ‘scotopic sensitivity’, which she claimed could be responsible for the inability of some people to read fluently and the symptoms of which could be ameliorated by the wearing of prescribed colored lenses. The scientific literature does not support the use of colored lenses as a useful intervention for children with reading disability.
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Prior Approval:
Not applicable
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Policy:
Orthoptics may be considered medically necessary for up to 12 visits in a calendar year, only for those patients with a diagnosis of convergence insufficiency (ICD-9 code 378.83).
Orthoptics is considered investigational if the criteria listed above are not met.
The treatment of scotopic sensitivity syndrome, also known as Irlen syndrome, with the use of colored transparencies or colored lenses is considered investigational for all applications.
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Procedure Codes and Billing Guidelines:
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Selected References:
- Institute For Clinical Systems Improvement’s Technical Assessment Report TA #68; Vision Therapy, January 2003
- National Guideline Clearinghouse; Esotropia and exotropia. [NGC:2770] March 2003
- Ziring PR, et al. Learning Disabilities, Dyslexia, and Vision: A Subject Review (RE9825). American Academy of Pediatrics Policy Statement Volume 102, No 5 November 1998, 1217-1219.
- Robinson GL, Foreman PJ. Scotopic sensitivity/Irlen Syndrome and the use of coloured filters: a long-term placebo controlled and masked study of reading achievement and perception of ability. Perceptual and Motor Skills1999August;89(1):83-113.
- Simmers AJ, Bex PJ, Smith FK, Wilkins AJ. Spatiotemporal visual function in tinted lens wearers. Investigative Ophthalmology and Visual Sciences 2001 March;42(3):879-84.
- Scheiman M, Mitchell GL, Cotter S, Cooper J, Kulp M, Rouse M, Borsting E, London R, Wensveen J; Convergence Insufficiency Treatment Trial Study Group. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol. 2005 Jan; 123(1):14-24.
- American Academy of Pediatrics. Learning Disabilities, Dyslexia, and Vision: A Subject Review. Pediatrics 1998; 102(5):1217-1219. A statement of reaffirmation for this policy was published on August 1, 2008. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;102/5/1217)
- Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008 Oct;126(10):1336-49.
- ECRI Institute. Vision Therapy for Eye Disorders. Plymouth Meeting (PA): ECRI Institute; 2010 Jan 27. 14 p. [ECRI hotline response]. Also available: http://www.ecri.org.
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Policy History:
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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