Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vision therapy, as well as, authorization and coverage for future vision therapy services. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees convergence insufficiency. A review of the record indicates that the enrollee has been diagnosed with, marked convergence insufficiency, binocular dysfunction and headaches. A visit note indicated the enrollee had occasional headaches, difficulty with sustaining near point work, and occasionally saw double. The provider noted spectacle lenses were recommended for near work and recommended weekly in-office neuro-optometric therapy sessions with periodic progress evaluations.The submitted documentation fails to demonstrate the medical necessity of the service at issue. In-office vision therapy for the treatment of the patients diagnoses is not medically necessary and does not meet the standard of care. Home-based therapies and observation for convergence insufficiency is the prevailing treatment due to the cost-effective nature of this remedy and the lack of evidence for and standardization of office-based treatments. In-office vision therapy may be helpful for convergence insufficiency, but studies have not shown it to be superior to at-home treatment. The health plan is justified in denying coverage for office therapy before home-based treatment has been used. In-office vision therapy is typically discouraged for the treatment of headaches, childhood reading disabilities and dyslexia as it often robs time and family resources that could be used for providing appropriate support, educational interventions, and medical treatments for the child.At issue in this case is whether vision therapy is medically necessary for the beneficiary. The medical literature contains weak to moderate evidence that office-based vision therapy may be beneficial for children with convergence insufficiency. A randomized clinical trial has demonstrated that a group of patients aged 9 to 17 has shown greater symptomatic improvement after 12 weeks of office-based vergence/accommodative therapy with home reinforcement, than with less intensive home based treatments. These results were obtained with a very specific protocol of office and home-based therapy. The term vision therapy is relatively general and a standardized method of treatment for convergence insufficiency does not exist. In this case, a 12 to 16 week group of therapy sessions was recommended for treatment of poor accommodation and other non-specific dysfunctions. Concerning the treatment of poor accommodation or symptoms of headache and dizziness, there is no evidence to support the use of vision therapy. Therefore, the requested vision therapy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in ophthalmology and is actively practicing. The reviewer is an expert 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.