Convergence Insufficiency denials in California external review

What the reviewers wrote

Where the denial was overturned

An enrollee has requested reimbursement for vision therapy. Current concepts in convergence insufficiency describe this as a condition in which an individual has difficulty with reading “at near” because of their inability to bring their eyes close together. Colleagues have noted that convergence insufficiency can develop following head trauma. While the standard treatment for patients with convergence insufficiency would be to start with home-based exercises including pencil push-ups, studies such as the Comparison of Three Vision Therapy Approaches by colleagues have shown that it is not unreasonable to start office-based vision therapy, which has also been shown to be effective. In this case, the patient’s initial examination clearly documented objective evidence of convergence insufficiency. The patient’s near point of convergence was at and exophoria was also noted.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for vision therapy with a developmental optometrist. Findings: Three medical professional reviewers found that there is sufficient support for the requested services in this patient’s case. The Convergence Insufficiency Treatment Trial showed that office-based vision therapy is an effective treatment for convergence insufficiency. Long-term findings post therapy showed that patients maintained improvements after one year.

Where the denial was 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 enrollee’s 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.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for continued orthoptic training for treatment of her binocular vision disorder. Findings: The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The goal of orthoptic therapy is to stimulate and normalize accommodative, oculomotor and vergence abilities. The endpoint of orthoptic therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. Eye conditions such as convergence insufficiency, accommodative insufficiency, and ocular motor dysfunction are successfully treated with orthoptic therapy.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving convergence insufficiency, then check the rights and deadlines that apply to your plan.