Vision Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for the following: (1) in-person physical therapy service (3 times a week for 1 hour); (2) in-person occupational therapy services (1 time a week for 30 minutes); (3) in-person vision therapy services (1 time a week for 30 minutes); and (4) in-person speech therapy with augmentative and alternative communication (AAC) services (2 times a week for 30 minutes). The submitted documentation supports the medical necessity of a portion the requested services. Medical literature note that the impact of weight-bearing activities appears to be site specific, and a greater frequency of weight-bearing activities is related to greater areal bone mineral density of the lumbar spine in growing girls.

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.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent requested authorization and coverage for vision therapy. The enrollee has refractive amblyopia of the left eye and suppression of binocular vision. He has been wearing glasses for about two years. His eye exam noted 20/40 vision in the left eye. The record indicates the enrollee’s right eye is patched four hours per day. The recommendation was for this process to continue. The enrollee’s mother was told a trial vision therapy could be done to work on bilateral integration, spatial awareness, eye-hand coordination, primitive reflex integration, and the development of gross motor/foundation movement. A progress note indicated the vision therapy was going well and the therapy should be continued. The medical record indicates the enrollee’s comprehensive testing revealed a primary diagnosis of Amblyopia of eye (H53.009).

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.

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 Vision Therapy, then check the rights and deadlines that apply to your plan.