Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Orthoptic/Pleoptic Training

Policy #:07.13.01g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin 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 Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. Individual benefits must be verified.

When a benefit exists, orthoptic/pleoptic training for the correction of oculomotor dysfunction is considered medically necessary and, therefore, covered to evaluate and train an individual or caregiver to continue a home training program for the individual with at least one of the following conditions:
  • Nonstrabismic binocular vision disorders
    • Convergence insufficiency and excess
    • Divergence insufficiency
    • Fusional vergence dysfunction
    • Vertical heterophoria
  • Strabismus
    • Intermittent exotropia
    • Intermittent esotropia
    • Hypertropia
  • Accommodative disorders
    • Accommodative insufficiency
    • Accommodative excess
    • Accommodative infacility
  • Diplopia
  • Before-and-after eye muscle surgery in order to strengthen fusional reserves
  • A lack of depth perception resulting from a traumatic brain injury

A provider who has been trained in the diagnosis and treatment of visual disorders must provide the initial education and training in order for the individual or caregiver to continue a home training program.

Because the available published literature does not support the use of exercise prisms and special tinted lenses in orthoptic/pleoptic training, they are considered not medically necessary and, therefore, not covered to diagnose or treat an illness or injury.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

Orthoptic/pleoptic training is not considered an appropriate treatment plan for learning disabilities, learning difficulties, or reading problems; however, an individual may receive orthoptic/pleoptic training, provided they meet medical necessity criteria.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, orthoptic/pleoptic training is covered under the medical benefits of the Company's products when the medical necessity criteria listed in the medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

The sense of vision is complex and comprises three distinct functional areas that align together to create efficient visual abilities:
  • Visual pathway integrity: includes eye health, visual acuity, and refractive status
  • Visual skills: includes accommodation (eye focusing), binocular vision (eye teaming), and eye movements (eye tracking)
  • Visual information processing: includes identification, discrimination, spatial awareness, and integration with other senses (e.g., eye-hand coordination, visual motor integration)

Normal human eyes are spaced 50 to 65 mm apart and are anatomically located so as to be directed straight forward. Because there is a small horizontal separation between the eyes, the images in each eye differ slightly. These two slightly different images are superimposed (fused) in the brain, and the object is perceived as having height, width, and depth in one stereoscopic image. To be superimposed and perceived in three dimensions, the horizontal separation of the eyes must be neither too little nor too great; each eye must be directed simultaneously to the same object. The image in each eye must have approximately the same degree of clarity, size, and refraction.

Image fusion requires sensitive and intact sensory and motor mechanisms. The sensory mechanism provides the visual sensation of the form, color, direction, and motion of the stimulus. It consists of the retina and its combined connections in the brain, in conjunction with the muscles of the ciliary body and the iris, which controls the clarity and amount of light entering the eye. Motor assistance from the 12 striated extraocular muscles maintains the direction of the two eyes on the same object. An abnormality in either the sensory or the motor mechanism may lead to faulty vision, abnormal positioning of the eyes, or both.

Orthoptic/pleoptic training employs eye exercises to correct oculomotor dysfunction by improving the eye muscles so an individual can obtain a comfortable binocular vision, which results when both eyes work together simultaneously, equally, and accurately.

The Committee on Children with Disabilities, which includes the American Academy of Pediatrics (AAP), the American Academy of Ophthalmology (AAO), and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), issued a statement in concert regarding the use of orthoptics and pleoptics in the treatment of children with learning disabilities. The policy statement presents a consensus that there is limited scientific evidence for the efficacy of eye exercises (vision therapy) or the use of special tinted lenses or exercise prisms in the correction of developmental problems or neurologic conditions in the pediatric population. Moreover, the statement concludes that educational remediation is the only proven solution to learning disabilities; affected children are most likely to benefit from remedial instruction given by qualified educators in a school setting with a low student-to-teacher ratio. Therefore, orthoptic/pleoptic training is not considered an appropriate treatment plan for children with learning disabilities, learning difficulties, or reading problems.

There are no published studies or data regarding exercise prisms and special tinted lenses that recommend the use of these devices as an adjunct to orthoptic/pleoptic training. Current standards among practicing ophthalmologists suggest that the use of exercise prisms and special tinted lenses in the treatment of vision disorders, including depth perception problems, have no proven value.

After review of the available published literature regarding the efficacy of orthoptic/pleoptic training and consultation with practicing ophthalmologists about current standards for generally accepted practices, orthoptic/pleoptic training has been identified as potentially beneficial treatment of the following conditions:
  • Nonstrabismic binocular vision disorders
  • Strabismus
  • Accommodative disorders
  • Diplopia
  • Convergence/divergence disorders
  • Before-and-after eye muscle surgery in order to strengthen fusional reserves
  • A lack of depth perception resulting from a traumatic brain injury

References


American Optometric Association Consensus Panel. Optometric clinical practice guideline care of the patient with accommodative and vergence dysfunction. St. Louis, MO: American Academy of Opthalmology; 2011. Available at: https://www.aoa.org/documents/optometrists/CPG-18.pdf. Accessed January 2, 2018.

American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern® Guidelines. Amblyopia. San Francisco, CA: American Academy of Opthalmology; 2017. Available at: https://www.aao.org/preferred-practice-pattern/amblyopia-ppp-2017. Accessed January 2, 2018.

Figueira EC, Hing S. Intermittent exotropia: comparison of treatments. Clin Experiment Opthalmol. 2006;34(3):245-51.

Handler SM, Fierson WM. American Academy of Pediatrics. Section on Ophthalmology and Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists. Learning disabilities, dyslexia, and vision. Pediatrics,2011;127(3):e818 - e856. Also available on the AAP Web site at: http://pediatrics.aappublications.org/content/pediatrics/127/3/e818.full.pdf. Accessed January 2, 2018.

Learning disabilities, dyslexia, and vision: a subject review. Committee on Children with Disabilities, American Academy of Pediatrics (AAP) and American Academy of Ophthalmology (AAO), American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Pediatrics. 1998;102(5):1217-19. Also available on the AAP Policy Web site at: http://pediatrics.aappublications.org/content/pediatrics/102/5/1217.full.pdf. Accessed January 2, 2018.

Momeni-Moghaddam H, Kundart J, Azimi A, et al. The effectiveness of home-based pencil push-up therapy versus office-based therapy for the treatment of symptomatic convergence insufficiency in young adults. Middle East Afr J Ophthalmol. 2015;22(1):97-102.

Newell FW. Ophthalmology Principles and Concepts. 8th ed. St. Louis, MO: Mosby; 1996: 406-425.

Optometrists Network. Children with special needs: Children's visual health. [Optometrists Network Web site]. Available at: http://www.children-special-needs.org. [The link to this reference is no longer active on the Optometrists Network Web site.] Accessed June 29, 2015.

Wills Eye. Strabismus. [Wills Eye Hospital Web site]. 10/14/2011. Available at: https://www.willseye.org/disease_condition/strabismus/. Accessed January 2, 2018.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

92065


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

H50.21 Vertical strabismus, right eye

H50.22 Vertical strabismus, left eye

H50.30 Unspecified intermittent heterotropia

H50.311 Intermittent monocular esotropia, right eye

H50.312 Intermittent monocular esotropia, left eye

H50.32 Intermittent alternating esotropia

H50.331 Intermittent monocular exotropia, right eye

H50.332 Intermittent monocular exotropia, left eye

H50.34 Intermittent alternating exotropia

H50.53 Vertical heterophoria

H51.11 Convergence insufficiency

H51.12 Convergence excess

H51.8 Other specified disorders of binocular movement

H52.521 Paresis of accommodation, right eye

H52.522 Paresis of accommodation, left eye

H52.523 Paresis of accommodation, bilateral

H52.529 Paresis of accommodation, unspecified eye

H52.531 Spasm of accommodation, right eye

H52.532 Spasm of accommodation, left eye

H52.533 Spasm of accommodation, bilateral

H52.539 Spasm of accommodation, unspecified eye

H53.2 Diplopia

H53.32 Fusion with defective stereopsis

H53.33 Simultaneous visual perception without fusion

Z48.810 Encounter for surgical aftercare following surgery on the sense organs

Z51.89 Encounter for other specified aftercare



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

07.13.01g:
03/14/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on cervical traction for in-home use.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 06/28/2017
Version Issued Date: 06/28/2017
Version Reissued Date: 03/14/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.