Medical Policy: 09.03.02
Original Effective Date: March 1988
Reviewed: March 2016
Revised: March 2016
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:
Orthoptic training or vision therapy appears to be beneficial in the treatment of symptomatic convergence insufficiency and can be provided through home based therapy. Home based therapy 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.
For convergence insufficiency the vision therapy usually incorporates specific treatments in order to achieve the following:
A vision therapy program for convergence insufficiency consists of at least 12 weeks of home based treatment (15 minutes per day, five or more days per week). For individuals whose symptoms have failed to improve with a trial of least 12 weeks of home based therapy, office based therapy may be considered for the treatment of continued symptomatic convergence insufficiency. The therapy is individualized, the procedures used and 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.
Convergence insufficiency can be complicated by:
Based on the available medical literature randomized clinical trials 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 a dozen and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program.
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.
Summary
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 a home based therapy program and supplemental office based therapy when home based therapy fails.
A vision therapy program for convergence insufficiency consists of at least 12 weeks of home based treatment (15 minutes per day, five or more days per week). For individuals whose symptoms have failed to improve with a trial of least 12 weeks of home based therapy, office based therapy may be considered for the treatment of continued symptomatic convergence insufficiency. Based on the available medical literature randomized clinical trials 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 a dozen and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program.
Vision Therapy – Orthoptic Training for Other Indications
The therapeutic goal of vision therapy is to correct or improve visual dysfunction. Visual dysfunctions. Dysfunction 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, Dyslexia and Vision
Learning disabilities constitute a diverse group of disorders in which children generally possess at least average intelligence 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, poorly defined patient criteria. In addition, the use of visual therapies is not supported by current specialty society guidelines.
Practice Guidelines and Position Statements
American Academy of Ophthalmology
Convergence Insufficiency
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.
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.
Not applicable
Medically Necessary
Office based orthoptic training/vision therapy in children and adolescents may be considered medically necessary for the treatment of symptomatic convergence insufficiency up to 12 visits only, if following a minimum of 12 weeks of home based therapy (e.g. push-up exercises using accommodative target of letters, numbers or pictures; push-up exercises with additional base-out prism exercises; jump-to-near convergence exercises; stereogram and convergence card exercises; and recession from a target and maintain convergence for 30-40 seconds), symptoms have failed to improve.
Office based orthoptics training/vision therapy in children and adolescents for the treatment of symptomatic convergence insufficiency exceeding 12 visits will be considered not medically necessary.
A vision therapy program for convergence insufficiency consists of at least 12 weeks of home based treatment (15 minutes per day, five or more days per week). For individuals whose symptoms have failed to improve with a trial of least 12 weeks of home based therapy, office based therapy may be considered for the treatment of continued symptomatic convergence insufficiency. Based on the available medical literature randomized clinical trials 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 a dozen and can typically be prescribed on a 1-2 session per week basis in conjunction with a home program. If a patient remains symptomatic after 12 weeks of orthoptic training/vision therapy alternative interventions should be considered (i.e. continued home therapy program, home based computer vergence exercises, behavioral visual therapy, anti-suppression or surgery). Therefore, visits that exceed 12 office based therapy visits will be considered not medically necessary.
Investigational
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.
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.