Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Saccadic Eye Movement and Paresis of Accommodation

Treatment: current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation

The insurer denied coverage for current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation

The denial is upheld

The patient has a history of cerebral palsy who has been involved in visual therapy to help tracking and visual processing.  The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome in this patient. 

Vision therapy is an individualized program of prescribed activities using specialized instruments and computer technology to redevelop and strengthen the neuro-connections between the brain and the visual system, which improves deficient visual skills. By repeating your vision therapy exercises, you'll develop skills that will allow you to succeed in work, academia, and sports environments. Vision therapy is the treatment of choice for diagnosed visual disorders that contribute to reading and learning difficulties. Ongoing evidenced-based clinical research supports the efficacy of vision therapy.

Current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation does have final approval from the appropriate regulatory bodies for this diagnosis.

The orthoptic paradigm for disorders of binocular vision involves generating clinical data through a standardized orthoptic evaluation, interpreting the results to define the orthoptic status of the patient, and to use this information to formulate the best management approach     

This patient is not a good candidate for current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation.

This patient has a diagnosis of cerebral palsy. The therapies that play an important role in treating cerebral palsy are physical therapy, muscle training and exercises can help your child's strength, flexibility, balance, motor development and mobility, occupational therapy, speech and language therapy, and recreational therapy. With cerebral palsy the movement of the eyes are different from those of a child with strabismus. For activities of daily living rather than trying to read (goal of vision therapy) are more important.     

Risks with visual or pleoptic training do not have a risk of treatment in cerebral palsy.     

The ophthalmological evaluation is different from those in optometry for visual training. Ophthalmology is interested in visual acuity and lack of diplopia. With cerebral palsy the movement of the eyes are different from those of a child with strabismus. For activities of daily living rather than trying to read (goal of vision therapy) are more important.                                                    

The carrier's denial of current procedural terminology (CPT) code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation should be upheld