Medical Policy: 09.03.02
Original Effective Date: March 1988
Reviewed: March 2017
Revised: March 2017
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 (health professional uniquely trained to evaluate and manage childhood and adult eye movement abnormalities).
Orthoptic training/vision therapy has been proposed for individuals with the following visual dysfunctions:
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), eyestrain, eye fatique, tension in and around the eyes, headaches when reading, and squinting or closing of one eye. 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.
Convergence insufficiency and stereoacuity is documented by:
For convergence insufficiency the vision therapy usually incorporates specific treatments, e.g., 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; recession from a target; and/or computer programs, as well as behavioral therapies, in order to achieve the following:
Convergence insufficiency can be complicated by:
Based on the available medical literature several randomized controlled clinical trials and nonrandomized comparative studies have demonstrated that vision therapy/orthoptic training improves symptoms of convergence insufficiency and that the majority of children age 9 to 17 years were asymptomatic after a 12 week treatment program,15 minutes per day five or more days per week. The most direct evidence comes from a 2008 RCT that demonstrated office based vision/orthoptic training improves symptoms of convergence insufficiency in a greater percentage of patients than a home based vision exercise program consisting of pencil push-ups or home computer vision exercises. Subanalysis of this RCT demonstrated improvements in accommodative vision, parental perception of academic behavior, and specific convergence insufficiency related symptoms. The published clinical studies show that a limited number of office visits are required for resolution of convergence insufficiency. The average number of office visits for convergence insufficiency is usually less than twelve and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program.
Home based therapy to reinforce the developing visual skills should include 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 and convergence card exercises; recession from a target; and maintaining convergence for 30 to 40 seconds. There is also a computer based orthoptic program known as Computer Vergence System (CVS). The program uses random dot stereograms to form pictures that require bi-foveal fixation to stimulate the vergence system. The program gradually increases the amount of vergence required to appreciate the stereogram picture and can monitor progression on line. This may be used as part of the home therapy program and 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.
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.
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.
Patients with convergence insufficiency can be treated by various strategies, depending on the severity of symptoms. Studies have shown that vision therapy is the treatment of choice for convergence insufficiency. The recommended treatment includes an office based therapy program with supplemental home based therapy.
Based on the available medical literature randomized controlled clinical trials and nonrandomized comparative studies have demonstrated that vision therapy/orthoptic training improves symptoms of convergence insufficiency and that the majority of children age 9 to 17 years were asymptomatic after a 12 week treatment program. The published clinical studies show that a limited number of office visits are required for resolution of convergence insufficiency. The average number of office visits for convergence insufficiency is usually less than twelve and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program.
The therapeutic goal of vision therapy is to correct or improve visual dysfunction. Visual dysfunctions that purportedly are treatable by vision therapy include accommodative disorders – focusing problems, amblyopia, strabismus, ocular motility dysfunction – eye movement disorders, visual rehabilitation after traumatic brain injury or stroke, and treatment of learning disabilities including ADD/ADHD, dyslexia and other reading disabilities.
Most studies evaluating the efficacy of vision therapy for visual disorders are small. In general, these studies are poorly designed and significant methodological flaws, and the data derived from them are relatively weak and inconclusive. There is some evidence to support the use of vision therapy that involves occlusion as a treatment for amblyopia and vision therapy that involves prism adaptation prior to surgery administered as a treatment for acquired estropia. However, large well designed studies comparing vision therapy with other treatment modalities, standardization of outcome measurements and the criteria for defining patient selection criteria are needed to evaluate vision therapy for visual dysfunctions adequately.
Learning disabilities constitute a diverse group of disorders in which children generally possess at least average intelligence and have problems processing information or generating output. Their etiologies are multifactorial and reflect genetic influences and dysfunction or brain systems. Reading disability, or dyslexia, is the most common learning disability. It is a receptive language-based learning disability that is characterized by difficulties with decoding, fluent word recognition, rapid automatic naming, and/or reading comprehension skills. These difficulties typically result from a deficit in the phonologic component of language that makes it difficult to use the alphabetic code to decode the written word. Early recognition and referral to qualified professionals for evidence-based evaluations and treatment are necessary to achieve the best possible outcome. Because dyslexia is a language based disorder, treatment should be directed at this etiology. Remedial programs should include specific instruction in decoding, fluency training, vocabulary, and comprehension. Most programs include daily intensive individualized instruction that explicitly teaches phonemic awareness and the application of phonics. Vision problems can interfere with the process of reading, but children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions. Currently, there is inadequate scientific evidence to support the view that subtle eye or visual problems cause or increase the severity of learning disabilities. Scientific evidence does not support the claims that visual training, 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. Per the American Academy of Ophthalmology policy statement regarding learning disabilities, dyslexia and vision one of the recommendation states: diagnostic and treatment approaches for dyslexia and other learning disabilities that lack scientific evidence of efficacy such as behavioral vision therapy, eye muscle exercises, or colored filters and lenses are not endorsed or recommended.
Based on review of the medical literature there is lack of quality data on the efficacy of vision therapy for treating dyslexia and other reading and learning disabilities. Most of the study results were found to be inconsistent and the studies themselves are flawed by serious design limitations e.g. small sample sizes, and poorly defined patient criteria. In addition, the use of visual therapies is not supported by current specialty society guidelines.
Orthoptic training (vision therapy) is the primary treatment modality used by most eye care professionals for the treatment of convergence insufficiency (CI). The plasticity of the fusional convergence reflex system allows patients to improve their convergence amplitudes with simple exercises. There are numerous different types of eye exercises; however, the primary treatment modalities for CI include home based exercise, in-office exercises, computer vergence exercises or a combination of these. Some studies have suggested that performing both the home based exercises and the computer program is more effective than either modality performed on its own.
Eye care professionals will sometimes prescribe both in-office and home based CI exercises. Occasionally patients will require additional treatment strategies such as anti-suppression or extra time and assistance with the exercises and will require in-office treatment.
Conventional Convergence Exercises:
Idiopathic convergence insufficiency responds very well to convergence exercises and has a very high reported success rate. Published success rates vary between 70 to 80% depending on the patient population and study size.
In 2010, the American Optometric Assocation issued an optometric clinical practice guideline for the care of the patient with accommodative and vergence dysfunction that stated: Patients with convergence insufficiency (CI) can be treated by various strategies, depending on the severity of symptoms. Numerous studies have shown that vision therapy is the treatment of choice for CI. The recommended treatment includes in-office therapy and supplemental home therapy. Home therapy alone, which is less effective, may be prescribed when in-office therapy is not possible. To ensure its success, home therapy should be closely monitored for patient compliance and make adjustment when needed. For the patient who cannot participate in vision therapy, prescribed prisms may reduce the load on the vergence system, however, prisms do not always alleviate the pateint’s symptoms.
In 2011 (reaffirmed in 2014) The AAP, AAO, AAPOS and AACO issued a joint statement concerning pediatric learning disabilities, dyslexia and vision. For vision therapy, the statement concluded:
“Currently, there is no adequate scientific evidence to support the view that subtle eye or visual problems cause learning disabilities. Furthermore, the evidence does not support the concept that vision therapy or tinted lenses or filters are effective, directly or indirectly, in the treatment of learning disabilities. Thus, the claim that vision therapy improves visual efficiency cannot be substantiated. Diagnostic and treatment approaches that lack scientific evidence of efficacy are not endorsed or recommended.”
Note: See also Wellmark Provider Eye Care Guide, Noncovered Eye Care Services, Vision Therapies.
Office based orthoptic training/vision therapy to establish a home program may be considered medically necessary for the treatment of symptomatic convergence insufficiency up to 12 visits.
Office based orthoptics training/vision therapy for the treatment of convergence insufficiency exceeding 12 visits will be considered not medically necessary. Published clinical studies show that a limited number of office visits, usually less than twelve, are required for resolution of convergence insufficiency. Office visits are only necessary to help establish or support a home program.
Orthoptics training/vision therapy is considered investigational for all other conditions, including but not limited to the following:
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. Large well-designed studies comparing vision therapy with other treatment modalities, standardization of outcome measurements and the criteria for defining patient selection criteria are needed to evaluate vision therapy for visual dysfunctions adequately. Other than convergence insufficiency treatment, the optometric claims that orthoptic training/vision therapy improves visual efficiency cannot be substantiated and therefore is considered investigational.
Based on review of the medical literature there is lack of quality data on the efficacy of vision therapy for treating dyslexia and other learning and reading disabilities. Several small randomized controlled trials of vision therapy have been published, but these study results were found to be inconsistent and the studies themselves are flawed by serious design limitations e.g. small sample sizes and poorly defined patient criteria. In addition, the use of vision therapy is not supported by current specialty society guidelines. The American Academy of Pediatrics issued a joint statement that concludes vision therapy is ineffective in the treatment of learning disabilities and the claim that vision therapy improves visual efficiency cannot be substantiated. They go on to state diagnostic treatment approaches that lack scientific evidence of efficacy are not endorsed or recommended. Therefore, vision therapy is considered investigational for the treatment of dyslexia and other learning disabilities and reading.
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