Vision Therapy

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Medical Policy

Policy Number: OCA 3.40 Version Number: 20 Version Effective Date: 06/01/21

Product Applicability All Plan+ Products

Well Sense Health Plan Boston Medical Center HealthNet Plan Well Sense Health Plan MassHealth ACO MassHealth MCO

Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary The Plan considers vision therapy as a standard treatment option for certain conditions medically necessary when medical criteria are met. Prior authorization is required. It will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested use. The Plan’s Medically Necessary medical policy, policy number OCA 3.14, specifies the product- specific definitions of medically necessary treatment, and the Plan’s Experimental and Investigational Treatment medical policy, policy number OCA 3.12, indicates the product-specific definitions of experimental or investigational treatment. Review the member’s applicable benefit documents rather

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 1 of 21

than this Plan policy for coverage of standard vision services which may include eye glasses, frames, and/or contact lenses; benefits documents are available at www.bmchp.org for BMC HealthNet Plan members and at www.SeniorsGetMore.org for Senior Care Options members.

Description of Item or Service Vision Therapy (VT): Also known as vision training, orthoptics, optometric vision therapy, orthoptic vision therapy, eye training, or eye exercises, vision therapy includes the use of eye exercises and controlled visual tasks or procedures to correct or improve visual function. An individualized treatment plan for vision therapy (utilizing eye exercises or eye training) may also include the use of specialized equipment such as lenses, prisms, filters, and/or occlusion therapy (eye patching). Vision therapy is routinely used by ophthalmologists for the treatment of eye conditions, but ophthalmologists do not usually prescribe vision therapy except for confirmed, symptomatic convergence insufficiency. While all optometrists have some training in vision therapy, behavioral optometrists and developmental optometrists receive additional, targeted training related to vision therapy.

A 2014 joint statement by the American Academy of Pediatrics (AAP), American Association for Pediatric Ophthalmology and Strabismus (AAPOS), American Association of Certified Orthoptists (AACO), and the American Academy of Ophthalmology (AAO) Hoskins Center for Eye Care states that the only condition improved with vision exercises is convergence insufficiency. Vision therapy has been used with children who are having trouble with reading or learning activities. According to this joint statement, vision therapy may make reading more comfortable and allow for reading for longer periods of time, but the clinical utility and clinical validity of vision therapy has not been established in clinical studies to demonstrate improvement in decoding and comprehension.

Medical Policy Statement The Plan considers the use of vision therapy (up to 24 visits within 6 months of initiating treatment) medically necessary when the following criteria are met and documented in the member’s medical record, as specified below in item A and item B:

A. The member has ONE (1) of the following medical conditions documented in the member’s medical record, as specified below in item 1 or 2:

1. MassHealth or Senior Care Options (SCO) member has confirmed, symptomatic convergence insufficiency; OR

2. Qualified Health Plan (QHP) member has confirmed, symptomatic accommodative insufficiency, amblyopia, convergence insufficiency, or esotropia acquired (prior to surgery); AND

Vision Therapy

B. The member meets the applicable clinical criteria listed below, as specified below in item 1 (for the initial two [2] months of treatment) or item 2 (for continuing treatment after the initial two [2] months):

1. For the Initial Two (2) Months of Vision Therapy

ALL of the following criteria must be met for the initial two (2) months of vision therapy, as specified below in items a through g:

a. The initial evaluation includes quantifiable measurements to support the diagnosis and to establish the baseline against which follow-up evaluations can be measured; AND

b. There is an expectation that vision therapy will produce measurable improvement in a reasonable period of time; AND

c. The comprehensive treatment plan includes the projected period of treatment; AND

d. The number of visits per week and the total number of visits are determined based on the nature and severity of the problem being treated and the needs of the individual receiving treatment; AND

e. Member has a home program in addition to office visual therapy and documentation of compliance is included in the records; AND

f. Follow-up evaluations are conducted at least monthly and include quantifiable measurements and the percentage of improvement from the initial evaluation; AND

g. The provider documents all progress and any changes in the treatment plan; OR

2. For Continuing Treatment After the Initial Two (2) Months of Vision Therapy

ALL of the following criteria must be met for continuing treatment after the initial two (2) months of vision therapy, as specified below in items a through e:

a. Measurable improvement has been demonstrated within the first two months of treatment; AND

b. Monthly evaluations demonstrate continued improvement over the prior month’s evaluation; AND

c. The number of visits per week and the total number of visits are determined based on the nature and severity of the problem being treated and the needs of the individual receiving treatment; AND Vision Therapy

d. Member has a home program in addition to office visual therapy and documentation of compliance is included in the records; AND

e. The provider documents all progress and any changes in the treatment plan.

Limitations

A. Vision Therapy Provided to MassHealth and/or Senior Care Options (SCO) Members:

1. Vision therapy is no longer considered medically necessary once further improvement cannot be demonstrated.

2. The use of smartphone eye exercise applications is considered experimental and investigational.

3. When medical necessity criteria are NOT met in the Medical Policy Statement section of this policy for a MassHealth or SCO member, vision therapy is considered either NOT medically necessary or experimental and investigational, including but not limited to the treatment of ANY of the following conditions specified below in items a through d:

a. Language disorders including developmental delay; OR

b. Learning disabilities including attention deficit hyperactivity disorder (ADHD), dyslexia, and reading disabilities; OR

c. Visual field defects following stroke and traumatic brain injury; OR

d. Any other diagnoses where there is NOT adequate authoritative evidence demonstrating the effectiveness of vision therapy, including but not limited to ANY of the following conditions, as specified below in items (1) through (39):

(1) Accommodative esotropia;

(2) Accommodative insufficiency;

(3) Amblyopia;

(4) Anomalous (retinal) correspondence;

(5) Basic esophoria;

Vision Therapy

(6) Basic exophoria;

(7) Brown’s tendon sheath syndrome;

(8) Chronic progressive ophthalmoplegia;

(9) Congenital nystagmus;

(10) Convergence excess;

(11) Cyclophoria;

(12) Cyclotropia;

(13) Deprivation amblyopia;

(14) Dissociated vertical deviation;

(15) Divergence insufficiency;

(16) Duane’s syndrome;

(17) External ophthalmoplegia;

(18) Fourth cranial nerve palsies;

(19) Fusion with defective stereopsis;

(20) General binocular vision dysfunction;

(21) Hypertropia;

(22) Hypotropia;

(23) Latent nystagmus;

(24) Limited ductions;

(25) Microtropia;

(26) Monocular comitant esotropia;

(27) Monocular comitant exotropia; Vision Therapy

(28) Ocular motor dysfunction – abnormal oculomotor studies;

(29) Ocular motor dysfunction – deficiencies of pursuit eye movements;

(30) Ocular motor dysfunction – deficiencies of saccadic eye movement;

(31) Psychological disturbances;

(32) Simultaneous vision without fusion;

(33) Sixth cranial nerve palsies;

(34) Strabismus or strabismic amblyopia;

(35) Suppression of binocular vision;

(36) Third cranial nerve palsies, total or partial;

(37) Total ophthalmoplegia;

(38) Visual deprivation nystagmus; OR

(39) Vertical heterophoria.

B. Vision Therapy Provided to Qualified Health Plan (QHP) Members:

1. The vision therapy is no longer considered medically necessary once further improvement cannot be demonstrated.

2. The use of smartphone eye exercise applications is considered experimental and investigational.

3. When medical necessity criteria are NOT met in the Medical Policy Statement section of this policy for a QHP member, vision therapy is considered either NOT medically necessary or experimental and investigational, including but not limited to the treatment of ANY of the following conditions specified below in items a through e:

a. Language disorders including developmental delay; OR

b. Learning disabilities including attention deficit hyperactivity disorder (ADHD), dyslexia, and reading disabilities; OR

Vision Therapy

c. Visual field defects following stroke and traumatic brain injury; OR

(1) Anomalous (retinal) correspondence;

(2) Basic esophoria;

(3) Basic exophoria;

(4) Brown’s tendon sheath syndrome;

(5) Chronic progressive ophthalmoplegia;

(6) Congenital nystagmus;

(7) Convergence excess;

(8) Cyclophoria;

(9) Cyclotropia;

(10) Deprivation amblyopia;

(11) Dissociated vertical deviation;

(12) Divergence insufficiency;

(13) Duane’s syndrome;

(14) External ophthalmoplegia;

(15) Fourth cranial nerve palsies;

(16) Fusion with defective stereopsis;

(17) General binocular vision dysfunction;

(18) Hypertropia;

(19) Hypotropia; Vision Therapy

(20) Latent nystagmus;

(21) Limited ductions;

(22) Microtropia;

(23) Monocular comitant esotropia;

(24) Monocular comitant exotropia;

(25) Ocular motor dysfunction - abnormal oculomotor studies;

(26) Ocular motor dysfunction - deficiencies of pursuit eye movements;

(27) Ocular motor dysfunction - deficiencies of saccadic eye movement;

(28) Psychological disturbances;

(29) Simultaneous vision without fusion;

(30) Sixth cranial nerve palsies;

(31) Strabismus or strabismic amblyopia;

(32) Suppression of binocular vision;

(33) Third cranial nerve palsies, total or partial;

(34) Total ophthalmoplegia;

(35) Visual deprivation nystagmus; OR

(36) Vertical heterophoria.

Review the Plan’s Experimental and Investigational Treatment medical policy, policy number OCA 3.12, for the product-specific definitions of experimental or investigational treatment.

Vision Therapy

Definitions Accommodation: The eye's ability to adjust its focus by the action of the ciliary muscle, which increases the lens focusing power. When this accommodation skill is working properly, the eye can focus and refocus quickly and effortlessly, which is similar to an automatic focus feature on a camera.

Accommodative Insufficiency: A lack of focusing ability at a near distance. Symptoms include eyestrain, blurred vision, occasional or constant when doing near work (such as reading or using a computer), occasional and unusual sensitivity to light, excess tearing, headaches, and general fatigue. Any decrease in accommodation function among school children can have a negative effect on the child’s learning experience related to reading or other near tasks.

Amblyopia (Lazy Eye): Poor vision in an otherwise healthy eye that did not develop normal sight during early childhood. It is usually marked by blurred vision in one eye and favoring one eye over the other. Amblyopia is the most common cause of vision impairment among children. According to the American Academy of Ophthalmology, the standard treatment for amblyopia is occlusion therapy (eye patching of the non-amblyopic eye) or atropine penalization (with atropine instilled into the non- amblyopic eye to cause pupillary dilation) to reduce accommodation by forcing the amblyopic eye to be used for near-vision tasks. Other treatment options may include prescription lenses, prisms, and vision therapy

Convergence Insufficiency (CI): The inability of the eyes to turn inward and/or sustain an inward turn, causing a significant impact on near vision. Symptoms include eyestrain with reading and using a computer, headaches, loss of comprehension, difficulty concentrating, blurred or double vision, and eye fatigue. Vision therapy is an effective treatment option.

Esophoria: Conditions in which, when both eyes are open, each eye points accurately at the target. However, upon covering one eye, the covered eye turns inwards. Also known as over-convergence.

Esotropia (ET): Condition in which an eye is turned inward toward the nose. Esotropia is a type of strabismus. It is caused by a reduction in visual acuity, reduced visual function, high refractive error, traumatic brain injury, oculomotor nerve lesion, or eye muscle injury. Acquired/accommodation esotropia is defined as crossed eyes that usually develop with a child between the age of 6 months and 7 years of age (averaging at age 2.5 years old) that is intermittent at onset and becomes constant over time. According to the American Academy of Ophthalmology, the treatment is spectacle correction with glasses worn on a full-time basis. Additional treatments may include pharmacotherapy using miotic agents, prism adaptation, bifocal correction, and/or refractive surgery based on the member’s condition, age, and success with spectacle correction.

Exophoria: Conditions in which, when both eyes are open, each eye points accurately at the target. However, upon covering one eye, the covered eye turns outwards. Also known as under-convergence.

Vision Therapy

Exotropia (XT): Conditions in which an eye is turned outward toward the ear. Exotropia is a type of strabismus. It may also be called divergent strabismus, wandering eye, or wall eye(s). It is caused by a reduction in visual acuity, reduced visual function, high refractive error, traumatic brain injury, oculomotor nerve lesion, or eye muscle injury.

Hypertropia: A type of strabismus where one eye turns upward.

Hypotropia: A type of strabismus where one eye turns downward.

Learning Disability: A disorder that affects individual’s ability to either interpret what they see and hear or to link information from different parts of the brain. Learning disabilities can be divided into five broad categories: speech and language disorders, reading disorder, arithmetic disorder, writing disorder, and attention disorders.

Occlusion Therapy: The use of an eye patch with the sound (non-amblyopic) eye to stimulate the amblyopic eye to be used for visual tasks.

Orthoptics: A system of eye exercises to improve eye movement and visual tracking by strengthening eye muscles. Orthoptics is a limited form of optometric vision therapy and usually administered by an orthoptist who is a specialist that works under the supervision of an ophthalmologist.

Pleoptics: A method of eye exercises created to stimulate and train an amblyopic eye.

Strabismus: An anomaly of ocular alignment in which the two (2) eyes are directed to different points when looking at an object in space. Normally, in the absence of strabismus, the two eyes are directed to the same point when fixating on an object. This deviation of one eye may cause double vision and/or the suppression of vision in one eye. Strabismus is more common in children between the ages of 6 to 17 years, but it may also appear later in life. Strabismus is classified based on the direction of the deviation: esodeviations (inward), exodeviations (outward), and vertical deviations (up or down).

Applicable Coding The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Since the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for Vision Therapy

reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service.

Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines. Review the Plan’s Vision Services reimbursement policy, policy number 4.38, available at www.bmchp.org for reimbursement guidelines applicable for covered vision services.

CPT Code Description: Code Covered When Medically Necessary 92065 Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

Clinical Background Information Vision therapy is a nonsurgical clinical approach for treating functional visual deficiencies. Vision therapy includes a wide range of optometric treatment modalities such as lenses, prisms, filters, occluders, and specialized computer programs or instruments. Other modalities include eye exercise and behavioral modalities that are used for eye movement and fixation training with the overall goal to correct or improve specific dysfunctions of the vision system. Vision therapy is administered in an office setting under the guidance of an optometrist and requires a number of office visits with the length of the program varying from a few weeks to several months depending upon the severity of the visual condition being treated. Typically, patients are taught home exercises and activities to be done in conjunction with vision therapy to reinforce visual skills.

There have been many studies that have evaluated the efficacy of vision therapy for a variety of visual disorders, however; in general, the data is weak and derived from poorly controlled studies. There is some evidence from the available studies that vision therapy may improve certain visual impairments such as amblyopia, acquired esotropia, convergence insufficiency, and accommodative deficiencies.

Vision therapy is a controversial topic as there is no complete consensus between the opinions of specialists. Some ophthalmologists believe that eye exercises, lenses, prisms, and occlusion may benefit individuals with specific visual disorders; most do not believe that vision therapy is an effective treatment option for individuals with dyslexia and learning disabilities. Some optometrists advocate vision therapy for individuals with learning disabilities including dyslexia. A joint policy statement of the American Academy of Ophthalmologists, the American Academy of Pediatrics (AAP), and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) states that the only condition improved with vision exercises is convergence insufficiency and visual problems are rarely responsible for learning difficulties, with no scientific evidence supporting the use of vision therapy for learning disabilities. Vision Therapy

At the time of the Plan’s most recent policy review, no clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) for vision therapy. Determine if applicable CMS criteria are in effect for this service in a national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request for a Senior Care Options member.

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American Academy of Ophthalmology (AAO). AAO Pediatric Ophthalmology/Strabismus Preferred Practice Pattern Panel. Hoskins Center for Quality Eye Care. Esotropia and Exotropia. 2017 Nov. Accessed at: https://www.aao.org/preferred-practice-pattern/esotropia-exotropia-ppp-2017

American Academy of Ophthalmology (AAO). Fontenot JL, Bona MD, Kaleem MA, McLaughlin WM Jr, Morse AR, Schwartz TL, Shepherd JD, Jackson ML; American Academy of Ophthalmology Preferred Practice Pattern Vision Rehabilitation Committee. Vision Rehabilitation Preferred Practice Pattern®. Ophthalmology. 2018 Jan;125(1):P228-P278. doi: 10.1016/j.ophtha.2017.09.030. Epub 2017 Nov 4. PMID: 29108747.

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Vision Therapy

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Vision Therapy

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Vision Therapy

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Scheiman M, Cotter S, Kulp MT, Mitchell GL, Cooper J, Gallaway M, Hopkins KB, Bartuccio M, Chung I; Convergence Insufficiency Treatment Trial Study Group. Treatment of accommodative dysfunction in children: results from a randomized clinical trial. Optom Vis Sci. 2011 Nov;88(11):1343-52. doi: 10.1097/OPX.0b013e31822f4d7c. PMID: 21873922.

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Shin HS, Park SC, Maples WC. Effectiveness of vision therapy for convergence dysfunctions and long- term stability after vision therapy. Ophthalmic Physiol Opt. 2011 Mar;31(2):180-9. doi: 10.1111/j.1475- 1313.2011.00821.x. PMID: 21309805.

Trieu LH, Lavrich JB. Current concepts in convergence insufficiency. Curr Opin Ophthalmol. 2018 Sep;29(5):401-6. doi: 10.1097/ICU.0000000000000502. PMID: 29994854.

Vimont SN. Vision Training Not Proven to Make Vision Sharper. American Academy of Ophthalmology. 2017 Jul 26. Accessed at: https://www.aao.org/eye-health/tips-prevention/vision-training-not-proven- to-make-vision-sharper

Yalcin E, Balci O. Efficacy of perceptual vision therapy in enhancing visual acuity and contrast sensitivity function in adult hypermetropic anisometropic amblyopia. Clin Ophthalmol. 2014;8:49-53. doi: 10.2147/OPTH.S48300. Epub 2013 Dec 12. PMID: 24376340.

Wallace DK. Treatment options for symptomatic convergence insufficiency. Arch Ophthalmol. 2008 Oct;126(10):1455-6. doi: 10.1001/archopht.126.10.1455. PMID: 18852426.

Vision Therapy

Policy History Original Effective Original Original Policy Date* and Version Policy Owner Approval Date Approved by Number Regulatory Approval: 03/07/06 Medical Policy Manager as Quality and Clinical N/A Version 1 Chair of Medical Policy, Management Committee Criteria, and Technology (Q&CMC) Internal Approval: Assessment Committee 02/07/06 (MPCTAC) *Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Well Sense Health Plan New Hampshire Medicaid Product(s): 01/01/13 *Effective Date for Senior Care Options Product(s): 01/01/16

Policy Revisions History Revision Review Effective Date Summary of Revisions Approved by Date and Version Number 02/21/07 Added references. Version 2 02/21/07: Utilization Management Committee (UMC) 03/06/07: Q&CMC 03/11/08 No changes. Version 3 03/11/08: MPCTAC 03/25/08: UMC 04/15/08: QIC 02/24/09 No changes. Version 4 02/24/09: MPCTAC 02/24/09: UMC 03/25/09: QIC 02/01/10 Annual review, no changes. Version 5 02/22/10: MPCTAC 03/24/10: QIC 02/01/11 Updated references, no changes to criteria. Version 6 02/16/11: MPCTAC 03/23/11: QIC 02/01/12 Updated clinical criteria and changed the allowed Version 7 02/28/12: MPCTAC number of visits from 32 visits per year to up to 03/23/12: QIC 24 visits within 6 months, updated References and Limitations sections. 08/01/12 Off cycle review for Well Sense Health Plan. Version 8 08/17/12: MPCTAC Revised Summary statement, reformatted 09/06/12: QIC Medical Policy Statement, revised Applicable Coding introductory statement, updated code list (deleted diagnosis codes and reference to “without prior authorization”), revised Limitations. 11/01/12 Review for effective date 03/01/13. Updated 03/01/13 11/21/12: MPCTAC

Vision Therapy

Policy Revisions History references. Reformatted and added clinical Version 9 12/20/12: QIC criteria in Medical Policy Statement section. Reformatted Limitations section. Updated language in Applicable Coding section; deleted diagnosis codes and the note that specified diagnosis codes did not require prior authorization (since there are additional criteria that need to be met to obtain Plan prior authorization). Referenced the following policies: Experimental and Investigational Treatment, Medically Necessary, and Vision Services. Removed duplicate text in Clinical Background Information section. 08/14/13 Off cycle review for Well Sense Health Plan and Version 10 08/14/13: MPCTAC and merged policy format. Incorporate policy (electronic vote) 08/15/13 revisions dated 11/01/12 (as specified above) for 08/15/13: QIC the Well Sense Health Plan product; these policy revisions were approved by MPCTAC on 11/21/12 and QIC on 12/20/12 for applicable Plan products. 11/01/13 Review for effective date 12/01/13. Updated 12/01/13 11/20/13: MPCTAC references. Removed Well Sense Health Plan as Version 11 11/21/13: QIC an applicable product. 11/01/14 Review for effective date 03/01/15. Updated 03/01/15 11/19/14: MPCTAC references. Clarified language in the Medical Version 12 12/10/14: QIC Policy Statement section. Updated Limitations section. Changed review calendar. 11/25/15 Review for effective date 01/01/16. Updated 01/01/16 11/18/15: MPCTAC template with list of applicable products and Version 13 11/25/15: MPCTAC notes. Revised language in the Applicable Coding (electronic vote) section. 12/09/15: QIC 01/01/16 Review for effective date 03/01/16. 03/01/16 01/20/16: MPCTAC Administrative changes made to the Description Version 14 02/10/16: QIC of Item or Service, Applicable Coding, and References sections. 03/01/16 Review for effective date 05/01/16. Revised the 05/01/16 03/16/16: MPCTAC References, Clinical Background Information, and Version 15 04/13/16: QIC Reference to Applicable Laws and Regulations sections. 03/01/17 Review for effective date 04/07/17. Updated 04/07/17 03/15/17: MPCTAC References section. Version 16 03/01/18 Review for effective date 04/01/18. Updated 04/01/18 03/21/18: MPCTAC Description of Item or Service, References, and Version 17 Other Applicable Policies sections. Vision Therapy

Policy Revisions History 03/01/19 Review for effective date 06/01/19. 06/01/19 03/20/19: MPCTAC Administrative changes made to the Policy Version 18 Summary, Description of Item or Service, Definitions, Clinical Background Information, References, and Other Applicable Policies sections. Criteria revised in the Medical Policy Statement and Limitations sections. 01/01/20 Review for effective date 02/01/20. 02/01/20 01/15/20: MPCTAC Administrative changes made to the Definitions, Version 19 References, and Reference to Applicable Laws and Regulations sections. 03/01/21 Review for effective date 06/01/21. 06/01/21 03/17/21: MPCTAC Administrative changes made to the Definitions Version 20 and References sections. Criteria revised in the Medical Policy Statement and Limitations sections.

Last Review Date 03/01/21

Next Review Date 01/01/22

Authorizing Entity MPCTAC

Other Applicable Policies Medical Policy - Contact Lens and Scleral Lens, policy number OCA 3.28 Medical Policy - Experimental and Investigational Treatment, policy number OCA 3.12 Medical Policy - Medically Necessary, policy number OCA 3.14 Reimbursement Policy - Community Health Centers and Federally Qualified Health Centers, policy number 4.107 Reimbursement Policy - General Billing and Coding Guidelines, policy number 4.31 Reimbursement Policy - General Billing and Coding Guidelines, policy number SCO 4.31 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number 4.108 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy SCO 4.108

Vision Therapy

Reimbursement Policy - Outpatient Hospital, policy number 4.17 Reimbursement Policy - Outpatient Hospital, policy number SCO 4.17 Reimbursement Policy - Physician and Non Physician Practitioner Services, policy number 4.608 Reimbursement Policy - Physician and Non Physician Practitioner Services, policy number SCO 4.608 Reimbursement Policy - Vision Services, policy number 4.38

Reference to Applicable Laws and Regulations 42 CFR 405.1060. Code of Federal Regulations. Applicability of National Coverage Determinations.

42 CFR 438.100. Code of Federal Regulations. Public Health, Centers for Medicare & Medicaid Services. Managed Care. Enrollee Rights and Protections. Enroll Rights.

42 CFR Parts 438, 440, 456, and 457. Code of Federal Register. Vol. 81. No. 61. Medicaid and Children's Health Insurance Programs; Mental Health Parity and Addiction Equity Act of 2008; the Application of Mental Health Parity Requirements to Coverage Offered by Medicaid Managed Care Organizations, the Children's Health Insurance Program (CHIP), and Alternative Benefit Plans. Centers for Medicare & Medicaid Services (CMS). 2016 Mar 30.

78 FR 48164-69. Federal Register. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. 2013 Aug 7.

114.3 CMR 17.00. Code of Massachusetts Regulations. Division of Health Care Finance and Policy. Medicine.

130 CMR. Code of Massachusetts Regulations. Division of Medical Assistance.

130 CMR 402.000. Code of Massachusetts Regulations. Division of Medical Assistance. Vision Care Services.

130 CMR 440.00. Division of Medical Assistance. Code of Massachusetts Regulations. Early Intervention Program Services.

Disclaimer Information: + Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs. Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency Vision Therapy

policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members. The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

Vision Therapy