Medical Policy: 09.03.02
Original Effective Date: March 1988
Reviewed: March 2015
Revised: April 2014
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.
Orthoptics, also known as vision training or vision therapy, is a technique of eye exercises intended to improve or correct diagnosed visual dysfunctions. Orthoptic training is usually prescribed by an ophthalmologist, optometrist or orthoptists.
Orthoptic training/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
Orthoptic training or vision therapy is beneficial in the treatment of symptomatic convergence insufficiency. Convergence insufficiency is the inability to maintain binocular function (keeping the two eyes working together) while working at a near distance. Typically, one eye will turn outward (intermittent exotropia) when focusing on a word or object at near.
Symptoms of convergence insufficiency include diplopia (double vision) and headaches when reading. Many patients will complain that they have difficulty concentrating on near work (computer, reading, etc.) and that the written words blur after prolonged periods of reading or if reading when tired. Not all symptoms are present in every patient with convergence weakness.
Convergence insufficiency is diagnosed by an ophthalmologist, optometrist or orthoptist after obtaining a history of the patient’s symptoms and measuring convergence ability. The examination includes determining the distance from the eyes that the patient can hold the eyes together without double vision (near point of convergence) and the amount of prism that can be placed in front of the eyes at a particular distance before double vision is seen (fusional vergence amplitude). Presence of any refractive errors, eye muscle dysfunction, or weaknesses in accommodation (near focusing) should also be determined.
During a routine eye examination, convergence weakness may be diagnosed even without the above mentioned symptoms. Some patients test in the office as having poor convergence; however, they are asymptomatic. This may be the result of true convergence weakness, but is often found when the patient is distracted, shy, overly excited or does not understand the directions given. These patients should either be retested at another time or simply watched for symptoms of diplopia or headaches with near work. A patient who is not having difficulty with near tasks but tests positive for convergence insufficiency does not require any treatment but should be followed.
Conversely, a patient with adequate convergence may occasionally have symptoms at home or school consistent with convergence insufficiency. In these cases, a course of treatment for convergence weakness can be instituted and the patient followed by report of improvement in symptoms.
Convergence insufficiency and stereoacuity is documented by:
- Exodeviation at near at least 4 prism diopters greater than at far; AND
- Insufficient positive fusional vergence at near (positive fusional vergence (PFV) less than 15 prism diopters blur or break) on PFV testing using a prism bar; AND
- Near point convergence (NPC) break of more than 6 cm; AND
- Appreciation by the patient of at least 500 seconds of arc on stereoacuity testing.
Convergence insufficiency can often be treated by practicing convergence through exercises (eg, push-up exercises using 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). There is also a program available which may be used on a home computer to increase convergence ability. The results of the computer program are often followed by an eye care professional with print outs that can be brought in to the office visit.
For convergence insufficiency the vision therapy usually incorporates specific treatments in order to:
- Normalize the near-point of convergence
- Normalize fusional vergence ranges and facility
- Minimize suppression
- Normalize associated deficiencies in ocular motor control and accommodation
- Normalize accommodative/convergence relationship
- Normalize depth judgement and/or steropsis
- Integrate binocular function with information processing
A vision therapy program for convergence insufficiency consists of in-office (1-2 visits per week) and at-home exercises. Therapy is individualized, the procedures used and the duration of the therapy are dependent upon the nature and severity of the problem being treated and the specific needs and compliance of the patient. Generally, positive results can be achieved with 3 to 12 consecutive months of treatment.
Based on the American Optometric Association, Fact Sheets on Optometric Vision Therapy (Reimbursement Packet 2011), for convergence insufficiency the following is indicated regarding duration of treatment:
The required duration of treatment is commensurate with the severity and/or complexity of the problem:
- Convergence insufficiency usually requires a minimum of 12 hours of office therapy
- Convergence insufficiency can be complicated by:
- Restricted fusional ranges: up to an additional 12 hours of office therapy
- Suppression: up to an additional 6 hours of office therapy
- An accommodative element: up to an additional 8 hours of office therapy
- Other diagnosed vision anomalies such as ocular motor dysfunction and accommodative disorder, may require additional therapy
- Associated conditions such as stroke, head trauma or other systemic diseases may require additional therapy
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.
Follow-Up Care: At the conclusion of the active treatment regimen, periodic follow up evaluation should be provided. Therapeutic lenses may be prescribed in conjunction with the vision therapy.
Scotopic Sensitivity syndrome (SSS)
At a national meeting in 1983 Helen Irlen proposed treatment with tinted lenses for a specific group of adults with reading problems, which she originally called the “scoptic sensitivity syndrome” SSS (now also called the Irlen syndrome or the Meares-Irlen syndrome). General symptoms associated with SSS can include headaches, nausea, fatigue, burning eyes and tearing. The initial claims of Irlen syndrome were based on observations, students’ anecdotal accounts and no formal experimentation.
People with this syndrome are thought to suffer from perceptual dysfunctions that cause visual distortion, light sensitivity, visual stress, and visual fragmentation from sensitivities to particular wavelengths of light not attributable to ocular conditions. The Irlen method uses colored lenses and filters to reduce the offending wavelengths and correct the perceptual dysfunctions.
More recent published studies advocating the use of colored lenses and filters to treat reading difficulties or learning disabilities have continued to have serious flaws in their methods, including biased sample selection, small sample size, biased interpretation, heightened expectations, combination with traditional remediation techniques and insufficient control for the placebo effect to support the assertion. Some studies have claimed to detect some improvement in a few patients in one reading subskill but not in other areas. However, improvements in reading subskills do not necessarily translate into improvements in reading. Overall, study results have been inconsistent, many studies have shown that colored overlays and filters are ineffective. Many unreported studies have shown no effect of colored filters on measures of either reading performance or SSS symptoms. Also, many of the studies cited as proof of Irlen-lens efficiency actually have been found to be inconclusive after deeper analysis. Not only are some findings less meaningful than they first appear, the large variability in the methodology, techniques and largely negative results do not support the effectiveness of tinted lenses or filters in these patients.
Practice Guidelines and Position Statements
American Academy of Pediatrics, American Academy of Ophthamology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists (2011): Issued a joint statement concerning pediatric learning disabilities, dyslexia and vision. Scientific evidence does not support the claims that visual training/therapy, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision therapy, training glasses, prisms, and colored lenses and filters are effective direct or indirect treatments for learning disabilities. There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not participate. The reported benefits of vision therapy, including nonspecific gains in reading ability, can often be explained by the placebo effect, increased time and attention given to students who are poor readers, maturation changes, or the traditional educational remedial techniques with which they are usually combined. Other than convergence insufficiency treatment, the optometric claims that vision therapy improves visual efficiency cannot be substantiated.
This policy addresses office based orthoptic training. This policy does not address standard vision therapy with lenses, prisms, filters or occlusion (i.e. for treatment of amblyopia (occlusion therapy) or acquired estropia (prism adaptation therapy) prior to surgical intervention).
Orthoptics training/vision therapy (eg. push-up exercises an accommodation 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), will be considered medically necessary up to 12 visits only for those patients with a diagnosis of convergence insufficiency (ICD-9 code 378.83), requests for orthoptics training/vision therapy exceeding 12 visits will be subject to a medical review.
Orthoptics training/vision therapy is considered investigational for all other indications.
Based on peer reviewed literature the available data supporting the use of orthoptics training/vision therapy for indications other than convergence insufficiency is weak and inconclusive and derived primarily from uncontrolled studies with significant methodologic flaws. Other than convergence insufficiency treatment, the optometric claims that orthoptic training/vision therapy improves visual efficiency cannot be substantiated and therefore is considered investigational for all other indications.
The treatment of scotopic sensitivity syndrome (SSS), also known as Irlen syndrome, with the use of colored transparencies or colored lenses is considered investigational for all applications.
Based on peer reviewed literature there is insufficient evidence that the use of colored lenses and filters in the treatment of vision disorders, including depth perception; learning disabilities; learning difficulties or reading problems have any therapeutic value or impact on net health outcomes. Therefore, the use of colored lenses or filters is considered investigational for all applications.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 92065 for orthoptic and/or pleoptic training
- 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.
- ECRI Institute. Vision Therapy for Treating Eye Disorders. Plymouth Meeting (PA): ECRI Institute; 2012 May. [Hotline response]. Available at: http://ecri.org.
- Borsting E, Mitchell GL, Kulp MT, Scheiman M, et al. Improvement in academic behaviors after successful treatment of convergence insufficiency. Optom Vis Sci. 2012; 89(1):12-18.
- Henderson M, Questioning the benefits that coloured overlays can have for reading in students with and without dyslexia. Journal of Research in Special Educational Needs. 2012 June.
- American Academy of Pediatrics, Learning Disabilities, Dyslexia and Vision: A Joint Technical Report. Pediatrics Vol.127 No. 3 March 1, 2011. http://pediatrics.aappublications.org
- American Optometric Association. Fact Sheets on Optometric Vision Therapy, Reimbursement Packet. January 2011.
- National Guideline Clearing House. Care of the Patient with Accommodative and Vergence Dysfunction. www.guideline.gov
- American Association for Pediatric and Ophthalmology and Strabismus: Convergence Insufficiency; Vision Therapy. www.appos.org
Date Reason Action
August 2011 Annual review Policy renewed
July 2012 Annual review Policy renewed
June 2013 Annual review Policy revised
April 2014 Annual review Policy revised
March 2015 Annual review Policy renewed
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.