Appeal type: Experimental/Investigational
Decision: Upheld


The patient is a male child with history of myopia, esophoria, accommodative spasm, and poor tracking with reading for whom coverage of vision therapy service is requested.  When examined in mid-2019, his vision was found to be 20/200 Right Eye (OD) and 20/80 Left Eye (OS).  Fusion was not found with Worth 4-dot testing.  Bifocals were prescribed.  The patient's mother reports amazing progress with the treatment the patient has received.

The scientific evidence in peer-reviewed medical literature does not support that CPT codes 92065 and 92499 for vision therapy improved health outcomes for the patient's diagnoses.
Orthoptic vision therapy is not well recognized outside optometric literature. The United Kingdom's College of Optometrists commissioned a report (Jennings, 2000) to critically evaluate the theory and practice of behavioral optometry (vision therapy).  The report, which followed, concluded that there was a lack of controlled clinical trials to support behavioral management strategies.  The evidence in support of vision therapy as of 2008 was recently reevaluated and published (Barrett, 2009).  The available evidence was reviewed under 10 headings: (1) vision therapy for accommodation/vergence disorders; (2) the underachieving child; (3) prisms for near binocular disorders and for producing postural change; (4) near point stress and low-plus prescriptions; (5) use of low-plus lenses at near to slow the progression of myopia; (6) therapy to reduce myopia; (7) behavioral approaches to the treatment of strabismus and amblyopia; (8) training central and peripheral awareness and syntonics; (9) sports vision therapy; (10) neurological disorders and neuro-rehabilitation after trauma/stroke.  The report found a continued lack of controlled trials in the literature to support behavioral optometry approaches.  With the exception of the treatment of isolated convergence insufficiency and the use of prisms and visual rehabilitation in patients with brain disease/injury, the large majority of behavioral management approaches was not found to be evidence-based, and thus cannot be advocated.

In this case, the patient is not identified as having convergence insufficiency.  Rather, vision therapy services have been provided for a patient diagnosed with myopia, esophoria, accommodative spasm, and poor tracking with reading.

The patient is not identified as having a diagnosis for which vision therapy services could be considered appropriate.  Vision therapy is not recognized by the medical community as the best available treatment for this patient at this time. The requested vision therapy is not likely to be more beneficial than standard treatments/procedures.

The carrier's denial of coverage for the following codes for service:  92065-Orthoptic and/or pleoptic training, with continuing medical direction and evaluation; and 92499-Unlisted ophthalmological service or procedure should be upheld.

The carrier's denial of coverage for the following codes for date of service 9/7/18:  92065-Orthoptic and/or pleoptic training, with continuing medical direction and evaluation; and  92499-Unlisted ophthalmological service or procedure should be upheld.