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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for vision therapy. The enrollee has refractive amblyopia of the left eye and suppression of binocular vision. He has been wearing glasses for about two years. His eye exam noted 20/40 vision in the left eye. The record indicates the enrollees right eye is patched four hours per day. The recommendation was for this process to continue. The enrollees mother was told a trial vision therapy could be done to work on bilateral integration, spatial awareness, eye-hand coordination, primitive reflex integration, and the development of gross motor/foundation movement. A progress note indicated the vision therapy was going well and the therapy should be continued.   The medical record indicates the enrollees comprehensive testing revealed a primary diagnosis of Amblyopia of eye (H53.009). This diagnosis relates to the nerves and muscles of the vision system, not to routine vision services. Surgery is usually not indicated for these conditions and specifically not indicated for this particular enrollee. Literature notes it is now well recognized that orthoptic/convergence therapy provides excellent improvement in the clinical measurements and symptoms associated with convergence insufficiency. During therapy, eye care professionals use multiple types of eye exercises and typically include treatment modalities such as home based exercise, in-office exercise, computer convergence exercise or a combination of these. This type of therapy has been shown to be an effective treatment modality for many types of problems affecting vision, and for the management of convergence insufficiency. Vision therapy typically consists of a variety of treatments and rarely ever includes only orthoptics. Physical exercises and re-education of the eyes is often utilized in combination with orthoptics.  While the study noted above supports vision therapy for convergence insufficiency, the enrollee has amblyopia with anisometropia and astigmatism. Vision therapy has not been shown to be effective for this diagnosis. Literature notes significant evidence for the successful management of amblyopia with occlusion therapy and atropine. Literature notes the management of amblyopia remains challenging, mainly due to compliance issues and suboptimal treatment outcomes during occlusion and atropine penalization. Recent studies have found evidence of new ways of treating amblyopia particularly in regard to binocular treatment such as video gaming, and dichoptic training. These have shown small effects on visual acuity. Further robust clinical trials on these new treatment modalities are still warranted in order to establish their role in treating amblyopia. There is a lack of published data from well-designed studies proving the efficacy of this treatment for this enrollee's diagnosed conditions. This individual with refractive amblyopia of the left eye is not identified as a good candidate for vision therapy. Vision therapy is supported by studies for those with the diagnosis of convergence insufficiency. Literature notes several strategies are used to improve visual acuity in amblyopia. Although not always achievable, the goal of treatment is equal visual acuity between the two eyes. The use of glasses alone has also been established as a good first-line therapy for both anisometropic amblyopia (unequal focus between the two eyes causing chronic blur) and strabismic amblyopia (poor vision in one eye caused by one eye turning). Incorporating new technology with an understanding of the biological basis of amblyopia has led to enthusiasm for binocular treatment of amblyopia. Early work on perceptual learning, as well as more recent enthusiasm for iPad-based dichoptic training, has generated interesting and promising data for vision improvement in amblyopes. However, no new treatment has emerged from currently available evidence as superior to the traditional therapies in common practice today. The treatments are based on the childs age, visual acuity, and adherence and response to previous treatment as well as the childs physical, social, and psychological status.  Credentials/Qualifications: Three reviewers are board certified in ophthalmology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.