DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for vision therapy.

Definitions

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Orthoptics-exercises designed to improve accommodation (focusing) and binocular vision (eye muscle coordination). Orthoptics may be considered particularly useful in the treatment of strabismus (crossed or wandering eyes).

Pleoptics-exercises designed to treat amblyopia, particularly in association with eccentric fixation

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Prior authorization is required when service limit of 6 sessions per year are exceeded.

Procedures

Children Up to 21 Years of Age Only

Orthoptics and/or Pleoptic training vision therapy is covered for children to the age of 21 for treatment of strabismus and other disorders of binocular eye movements. Therapy is limited to a total of six sessions per calendar year. Prior authorization is required when service limits are exceeded. If improvement is not noted after four sessions, the member must be referred to an appropriate professional (e.g., neurologist or ophthalmologist) for further evaluation. A treatment plan is required. The therapy treatment plan and regimen, such as patching, lens fogging, red/green/Polaroid filters, other lens devices, is to be taught to the client, family, foster parents and/or caregiver during the therapy treatments.

Training is considered complete when one of the following goals is attained:

1. Subsequent services would be for maintenance of a functional ability; or

2. When the member has demonstrated no progress at two consecutive visits

Othoptics and pleoptics may be considered medically necessary for ANY of the following (not an all-inclusive list):

• Amblyopia; or
• Strabismus; or
• Accommodative dysfunction; or
• General binocular dysfunction.

A maximum of two (2) exercise sessions per week for one (1) treatment period of six (6) consecutive months (based on a seven (7)-day week beginning with the first treatment session may be considered medically necessary as prescribed by an optometrist or ophthalmologist and performed by an optometrist, vision therapist or an occupational therapist.

The following methods of therapy are considered not medically necessary:

• Vision therapy for the treatment of learning disabilities, poor school test scores, and behavioral problems; and
• Vision therapy performed to maintain a level of function; and
• Home computer orthoptic programs as there are no direct professional services rendered with home use.

Vision therapy beyond two (2) sessions per week for a six (6) month period as indicated in this policy will be considered not medically necessary.

Documentation will be required to substantiate medical necessity for further treatments beyond initial six months.

Vision therapy not meeting the criteria as indicated in this policy is considered not medically necessary and therefore non-covered.