Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Esotropia, Amblyopia, Hypermetropia 
 
Treatment: 92065 Orthoptic and/or Pleoptic Training, with continuing medical direction and evaluation

The insurer denied 92065 Orthoptic and/or Pleoptic Training, with continuing medical direction and evaluation. The denial was upheld.   

This is a young male patient with a diagnosis of esotropia and amblyopia of the right eye, hypermetropia of both eyes, and convergence insufficiency. He had a history of a perinatal stroke that resulted in right hemiparetic cerebral palsy, and wearing developmental lenses to assist in reducing the visual stress of his class as well as balance the focusing point in his eyes. He consulted an ophthalmologist for a visual evaluation. It had been reported that he had several years of home program of Syntonic Phototherapy to balance his nervous system and to help the visual system work with less effort and stress. His recent ophthalmology evaluation revealed that he still had some right esotropia and the ability to verbalize that he sometimes sees double. It was recommended that he undergo Optometric Vision Therapy.

While orthoptic vision therapy is not well recognized outside optometric literature, and is generally considered experimental and investigation for most diagnoses, upon review of the peer-reviewed medical literature, this conclusion is not limited to those in the medical field. 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...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, vision therapy services have been provided for a patient diagnosed with refractive amblyopia of the right eye (H53.021), generalized contraction of visual field, bilateral (H53.483), esotropia of the right eye (H50.51), and hypermetropia of both eyes (H52.03).  Convergence insufficiency was mentioned in the appeal.  However, it does not appear that convergence insufficiency was ever established as a diagnosis, and the records provided for review do not support a diagnosis of convergence insufficiency. 

According to the Convergence Insufficiency Treatment Trial Study Group (2008), convergence insufficiency is characterized by an exodeviation at near of at least 4 prism diopters greater than at far, a receded near point of convergence (NPC) break (greater or equal to 6 cm), and insufficient positive fusional vergence at near (PFV) (convergence amplitudes) (i.e., 30 or minimum PFV of 15 base-out blur or break).  In this case, the patient's findings are not consistent with a diagnosis of convergence insufficiency.  In this case, such information supporting a diagnosis of convergence insufficiency is not provided.  It is noted that the patient has an esodeviation. 
The health plan acted reasonably with sound medical judgment and in the best interest of the patient.                                                       

The carrier's denial of coverage for the requested procedure code 92065 Orthoptic and/or pleoptic training, with continuing medical direction and evaluation is upheld. The medical necessity is not substantiated.