Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a nine-year-old female who was born three months premature and was hospitalized for three months after birth. It has been reported she has developmental delay and develops headaches when reading. The patients parents have requested coverage for Orthoptics and reading glasses to treat the patients headaches. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is considered experimental.  Review of the medical literature reveals no evidence to support the efficacy of Orthoptics as superior to standard eye care modalities. Furthermore, in the case of this patient there is no evidence of strabismus or hyeropia. Moreover, there is no evidence the patient has undergone a complete eye examination. The patient has 20/20 vision with minimal refractive error. There is no clinical indication for Orthoptics and reading glasses based upon the information provided. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a nine-year-old female with a history of developmental delay and headaches while reading. She was born three months premature. A request has been made for Orthoptics and reading glasses. The Health Plan has denied authorization and coverage for the requested therapy indicating its efficacy has not been established.Orthoptics is a controversial treatment for many eye conditions. It is most commonly used for strabismus, i.e. exophoria or convergence insufficiency. Even in these specific entities it is generally not accepted by ophthalmologists as a valuable form of treatment. Certainly, in a nonspecific situation such as headache (as with this patient), there is no scientific data to support its usefulness. In fact, there is no evidence of a medical diagnosis of an ophthalmic disorder in this case. There is no proven scientific benefit of either Orthoptics or reading glasses for treatment of headaches in a nine-year-old patient. Accordingly, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a nine-year-old female who experiences headaches while reading. The patients provider has recommended Orthoptics and reading glasses. The Health Plan has denied authorization and coverage for the requested therapy indicating it is considered experimental.Review of the submitted clinical documentation reveals no evidence the patient has a medical condition requiring treatment. Furthermore, there is no evidence the proposed Orthoptic therapy would be beneficial in treating the patients symptoms. There is no clinical indication for Orthoptics and reading glasses in this case. As such, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.