Vision Therapy
Total Page：16
File Type：pdf, Size：1020Kb
bmchp.org | 888-566-0008 wellsense.org | 877-957-1300 Medical Policy Vision Therapy 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 + 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. 2 of 21 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 + 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. 3 of 21 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 + 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. 4 of 21 (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;