Currentblue cross blue shield - south dakotaPolicy N/A

Vision Therapy/Orthoptic Training

Policy governs coverage of office-based orthoptic training (vision therapy) for convergence insufficiency and other visual or learning disorders for Wellmark (Blue Cross Blue Shield - South Dakota) members. It describes when therapy is considered medically necessary, investigational, and visit limits.

Policy Summary

Payerblue cross blue shield - south dakota

PolicyVision Therapy/Orthoptic Training

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMarch 1988

Next Review DateJune 2025

Key ActionLimit coverage to up to 12 office visits for medically necessary convergence insufficiency and document failed home-based therapy when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

<=12visits considered medically necessary

12+visits considered not medically necessary

12whome therapy trial duration

2008,2019landmark RCTs

92065/92066listed procedure codes

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Coverage Criteria

Medically Necessary - Convergence Insufficiency

Covered when ALL of the following are met:

Primary coverage criteria: Patient has symptomatic convergence insufficiency confirmed by clinical findings (asthenopic symptoms at near) and objective measures consistent with convergence insufficiency; documentation of diagnosis by a qualified/licensed professional is provided.

See required documentation for specific objective measures.

Objective diagnostic thresholds: Objective findings meet diagnostic thresholds: near exodeviation at least 4 prism diopters greater at near than at distance; positive fusional vergence at near <15 prism diopters (blur or break); near point of convergence break >6 cm; and stereoacuity of at least 500 seconds of arc.near exodeviation ≥4 PD; PFV <15 PD; NPC break >6 cm; stereoacuity ≥500 sec arc

Policy guidelines define these thresholds.

Prior conservative therapy: A trial of home-based therapy of at least 12 weeks including specified exercises (e.g., push-up exercises with accommodative target, push-ups with base-out prisms, jump-to-near convergence exercises, stereogram convergence exercises, recession from a target, maintaining convergence for 30–40 seconds) has failed or office visits are to establish a home program.minimum ~12 weeks home-based trial

Clinical input supports office-based therapy when home-based therapy fails.

Visit limit: Planned office-based orthoptic training is limited to up to 12 visits to establish/support a home program.≤ 12 visits

Office-based orthoptic training exceeding 12 visits is considered not medically necessary.

Investigational indications

Not covered / investigational:

Investigational indications: Orthoptics training/vision therapy for visual disorders other than convergence insufficiency, including dyslexia, learning disabilities, and reading disabilities.evidence insufficient

Evidence does not demonstrate improved net health outcomes for these indications.

Initial therapy

Covered when ALL of the following are met:

Population and symptom severity: Patient meets trial-style symptomatic criteria (e.g., elevated CISS score consistent with symptomatic CI) with clinical findings such as receded near point of convergence and insufficient positive fusional vergence.CISS ≥16; near point convergency ≥6 cm

CISS and objective measures are outcomes used in key RCTs (CITT).

Intervention format and regimen: Planned treatment is office-based vergence/accommodative (orthoptic) training with home reinforcement delivered weekly for approximately 12–16 weeks with daily home exercises.weekly office visits for 12–16 weeks plus daily home exercises

Matches intervention schedules in key randomized trials.

Outcome measurement and documentation: Baseline and follow-up measurements are documented, including CISS scores, near point of convergence, positive fusional vergence, and accommodative measures when applicable.

Convergence insufficiency — medically necessary criteria

Covered when ALL of the following are met:

Convergence insufficiency coverage: Office-based orthoptic training may be considered medically necessary for symptomatic convergence insufficiency when objective measures document dysfunction and when the documented treatment plan specifies approximately 12 sessions (about 12 sessions over ~5 weeks) to evaluate response; prior adequate home-based therapy may be required per clinical input.~12 sessions over 5 weeks; see baseline measures

Supported by RCT evidence (2008 CITT) showing greater improvements with office-based therapy in children; later RCTs had mixed results.

Learning disabilities / reading improvement — not medically necessary

Not covered / unproven when ANY of the following apply:

Learning-disability indications: Orthoptic training intended to improve reading or learning outcomes (including dyslexia, reading disabilities, or general learning disabilities) due to visual factors.evidence insufficient

Systematic reviews and peer-reviewed studies have not demonstrated consistent improvements in reading or learning outcomes; major statements conclude insufficient evidence to support vision therapy for learning disabilities.

Contexts for Use

Practice and clinical guidance notes:

Clinical context for offering orthoptic training: Orthoptic/vision therapy modalities include home-based, in-office, computer-based, or combination approaches. In-office therapy is commonly used primarily for convergence insufficiency and accommodative/vergence dysfunction; it is often considered when home-based therapy fails or when patients need additional monitoring, anti-suppression strategies, or assistance performing exercises.

Clinical input and specialty guidance support office-based therapy when home-based therapy is inadequate or fails; home programs should include specified exercises.

Typical treatment course to assess response: Approximately 12 sessions over about 5 weeks are typically needed to assess response to office-based therapy; home-based therapy trials of ~12 weeks are recommended before considering office-based therapy.~12 sessions / ~5 weeks; home trial ~12 weeks

Trial schedules and duration are based on clinical trials and clinical input.

Professional recommendations and limitations: Major professional groups note that vision therapy is the primary treatment for convergence insufficiency but that there is no adequate scientific evidence supporting vision therapy or tinted lenses for learning disabilities; diagnostic and treatment approaches lacking sufficient evidence are not endorsed for learning-disability indications.

Orthoptics training/vision therapy is designated investigational for indications other than symptomatic convergence insufficiency. This includes, but is not limited to, treatment of visual disorders other than convergence insufficiency and neurodevelopmental conditions such as dyslexia, learning disabilities, and reading disabilities, because the available evidence is insufficient to demonstrate improved net health outcomes for these indications.

Applicability of trial results may be limited when study populations do not match the patient being considered. The evidence base excluded studies with duplicative or overlapping populations and noted relevance limitations (for example, some RCTs enrolled primarily children or excluded certain comorbid populations). Several adult trials were small or did not compare office-based to home-based therapy, so the generalizability of pediatric trial results to adults is limited.

Use of eye exercises, orthoptic training, or vision therapy specifically to improve reading, learning, or educational outcomes is not supported by clear scientific evidence. Systematic reviews and peer-reviewed studies have not demonstrated consistent improvements in functional reading or learning measures with these interventions outside the context of treating convergence insufficiency.

Major professional organizations have concluded that there is no adequate scientific evidence that vision therapy, tinted lenses, or related approaches treat learning disabilities or dyslexia. Joint statements from pediatric and ophthalmology organizations as well as optometric guidance emphasize that vision therapy is not proven to improve learning disabilities and that subtle visual problems are not established causes of these conditions.

Coverage for office-based orthoptic training/vision therapy for symptomatic convergence insufficiency is limited to a maximum of 12 office visits. Requests for treatment exceeding 12 visits will be considered not medically necessary.

Evidence for adults is less clear than for children. Several adult randomized trials were small and/or did not compare office-based therapy directly with home-based approaches; some showed objective improvements (near point of convergence, positive fusional vergence) but did not demonstrate consistent symptom benefit. Overall, trial results in adults are mixed.

Examples of therapies not supported when used solely to treat dyslexia or general learning problems include tinted lenses and eye-patching strategies, computerized vergence training, and other vision therapy techniques. Peer-reviewed studies have not demonstrated that these approaches produce clinically meaningful improvements in reading or learning outcomes.

Professional statements from organizations including the American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists indicate that claims vision therapy improves learning disabilities or dyslexia are not supported by adequate scientific evidence.

Coding and Billing

Coding referencedmixed

No codes listed

Covered CPT Codes (as listed)CPTCovered

92065	Orthoptic training; performed by a physician or other qualified health care professional.
92066	Orthoptic training; under supervision of a physician or other qualified health care professional.

Place/Type of Servicemixed

Type of Service: Vision	Place/type of service classification listed for orthoptic training.
Place of Service: Physician's Office	Place of service indicated in coding guidance.

inv-18: Near point of convergence (break) — key diagnostic threshold

Near point of convergence (break)> 6 cm (break)

Measurement contextMeasured as break distance from the nose during near fixation tasks

Improvement definition (trials)Improvement defined as a decrease of >4 cm from baseline

inv-19: Positive fusional vergence at near (blur or break) — key diagnostic threshold

Positive fusional vergence at near (blur or break)< 15 prism diopters (blur or break)

Passing criteria in trialsTo be classified as normal PFV, must pass Sheard's criteria and have PFV blur/break >15 PD

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization & Visit Limit

Prior approval is required per payer rules; note that office-based orthoptic training/vision therapy for symptomatic convergence insufficiency is considered medically necessary for up to 12 visits. Requests for more than 12 visits will be considered not medically necessary.

Prior approval applicability: verify prior authorization rules with Blue Cross Blue Shield - South Dakota before initiating treatment.
Visit limit: ≤ 12 office-based visits for convergence insufficiency (requests >12 visits are not medically necessary).

Documentation Required

Office-based Therapy Regimen & Population Must Be Specified

Office-based orthoptic training must specify the planned regimen and target population in the authorization request. Typical regimen documented in the evidence and guidance: weekly office visits with home-exercise reinforcement for approximately 12–16 weeks (commonly 12 weeks of in-office training followed by months of home training). Include planned frequency, duration, and home exercise program.

Background and Evidence Summary

Convergence insufficiency is a binocular vision disorder characterized by difficulty sustaining inward eye alignment for near tasks, producing symptoms such as eyestrain, headaches, blurred or double vision, and difficulty concentrating during near work. Orthoptic (vision) therapy techniques — for example, push-up exercises, prism-assisted convergence training, jump-to-near and stereogram convergence exercises — are intended to improve convergence and accommodative function and relieve these symptoms.

Definitions

inv-40: Orthoptics / Orthoptic training — definition and examples

DefinitionTechniques designed to correct accommodative and convergence insufficiency (convergence dysfunction)

Examples of exercisesPush-up exercises (letters/numbers/pictures), push-ups with base-out prisms, jump-to-near convergence exercises, stereogram convergence exercises, and recession from a target

ModalitiesDelivered as office-based in‑clinic training, prescribed home exercises, computer-based vergence programs, or combinations

inv-41: Convergence insufficiency (diagnostic components)

Core diagnostic componentsAsthenopic symptoms at near plus objective findings

Required objective findings (summary)Near exodeviation ≥4 PD greater at near; positive fusional vergence at near <15 PD (blur or break); near point of convergence break >6 cm; stereoacuity ≥500 seconds of arc

Policy Summary

Payerblue cross blue shield - south dakota

PolicyVision Therapy/Orthoptic Training

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMarch 1988

Next Review DateJune 2025

Key ActionLimit coverage to up to 12 office visits for medically necessary convergence insufficiency and document failed home-based therapy when applicable.

SourceLink

On This Page

CISS change documented; NPC and PFV recorded

These outcomes were primary measures in RCTs and define improvement/success.

See AOA guideline and joint AAP/AAO/AAPOS/AACO statement.

Improvement definition (trials)Improvement defined as an increase of ≥10 prism diopters from baseline

inv-20: Near vs far exodeviation difference — key diagnostic threshold

Near vs far exodeviation differenceNear exodeviation at least 4 prism diopters greater than at distance (≥4 PD)

Role in diagnosisRequired objective finding to document convergence insufficiency alongside symptoms

Measurement methodMeasured with prism cover testing comparing near and distance deviations

inv-21: Stereoacuity threshold — key diagnostic threshold

Stereoacuity thresholdPatient must appreciate at least 500 seconds of arc on stereoacuity testing

Documented as part of diagnostic criteriaStereoacuity testing used to document binocular function in convergence insufficiency

Relation to inclusion in trialsIncluded among objective measures reported in RCTs and policy guidelines

inv-22: Typical treatment sessions — approximately 12 sessions over 5 weeks

Typical treatment courseApproximately 12 sessions over 5 weeks

Purpose of courseCourse length reported as needed to assess results in trials and to establish home program

Visit limit guidancePolicy limits office-based orthoptic training to up to 12 visits for convergence insufficiency

Planned regimen example: weekly in-office sessions for ~12 weeks (12–16 total visits in protocols), plus prescribed daily home exercises (e.g., 15 minutes/day, 5 days/week) and description of home program.
Target population: symptomatic convergence insufficiency (children and adults as applicable).

Billing Rule

Prior Authorization / Coding Guidance

Prior authorization requests must include coding details. Use CPT 92065 for orthoptic training performed by a physician or qualified health care professional, and CPT 92066 for orthoptic training under supervision (each additional session reporting guidance). Ensure correct CPT reporting to avoid billing denials.

Use CPT 92065: Orthoptic training; performed by a physician or other qualified health care professional.
Use CPT 92066: Orthoptic training; under supervision of a physician or other qualified health care professional.
Incorrect or missing CPT codes (92065/92066) may lead to billing issues or denials.

Denial Risk

Insufficient Evidence for Learning-Disability Indications

Evidence is insufficient to support orthoptic training for learning disabilities, dyslexia, reading disabilities, or other visual disorders beyond convergence insufficiency. Requests for treatment aimed at these indications lack demonstrated net health benefit and are investigational.

Orthoptics considered investigational for: dyslexia, learning disabilities, reading disabilities, and other non-convergence visual disorders.
Diagnosis of learning disabilities must be by an appropriate licensed professional when claimed; however, orthoptic training for these indications remains investigational.

Documentation Required

Required Clinical Documentation

Required clinical documentation must support the diagnosis of convergence insufficiency and justify office-based therapy. Provide symptom assessment and objective clinical measures at baseline and planned follow-up.

Document asthenopic symptoms at near and difficulty sustaining convergence (e.g., CISS score).
Objective baseline measures: difference in near vs distance exodeviation (≥4 prism diopters), near point of convergence (NPC) break >6 cm, positive fusional vergence (PFV) at near <15Δ (blur or break), and stereoacuity (appreciation of ≥500 seconds of arc).
Clinical note: diagnosis by a qualified professional (ophthalmologist, optometrist, or appropriate clinician).
Include documentation that home-based therapy was tried and failed when applicable (see home-based therapy prerequisite).

Documentation Required

Documentation Should Include Baseline and Follow-up Measures

Documentation should include baseline and follow-up outcome measures to show response to therapy. Include validated symptom scores and objective convergence testing at initiation and at defined intervals.

Baseline and follow-up Convergence Insufficiency Symptom Survey (CISS) scores (document numeric scores and change).
Baseline and follow-up near point of convergence (NPC) and positive fusional vergence (PFV) measurements.
Record stereoacuity testing results and other functional outcomes.
Specify timing of follow-up (e.g., reassess after the planned in-office course ~12 weeks and longer-term follow-up at ~6–12 months as available).

Step Therapy

Home-based Therapy Prerequisite

Home-based therapy is expected as the usual first-line approach. Office-based orthoptic training is generally reserved for patients who have failed an adequate home-based trial (approximately 12 weeks). Include details of the home program attempted.

Minimum home-based trial: ~12 weeks of structured home exercises (examples below).
Home program components often include: push-up exercises with an accommodative target, push-ups with base-out prisms, jump-to-near convergence exercises, stereogram convergence exercises, recession from a target, and maintaining convergence for 30–40 seconds.
Document adherence and response to home therapy; if symptoms persist after ≥12 weeks, office-based therapy may be considered medically necessary.

Step Therapy

Consideration of Step Therapy / Sequencing

Step-therapy logic: home-based therapy is typically prescribed first; office-based therapy is considered for nonresponders. Clinical reviewers support office-based therapy when a comprehensive home program has failed.

Step 1: Initiate comprehensive home-based program and document adherence for ~12 weeks.
Step 2: If inadequate response, request prior authorization for office-based orthoptic training with submitted baseline and follow-up measures and a detailed in-office regimen.
Evidence context: RCTs show office-based + home reinforcement is more effective than some home-only programs in children, but sequencing and completeness of home regimens affect outcomes.

Note

Home Therapy Trial Recommended Before Office-based Therapy

Clinical input and trial evidence recommend a home therapy trial before initiating office-based therapy; reviewers noted home regimens often include more than pencil push-ups and should be comprehensive. Office-based care is supported for nonresponders.

Recommended home exercises (documented): push-up with accommodative target, push-up with base-out prism, jump-to-near convergence, stereogram convergence exercises, recession from a target, sustaining convergence for 30–40 seconds.
If home therapy was incomplete (e.g., only pencil push-ups), document why the home program was inadequate before approving office-based therapy.

Note

Usual Care Sequencing

Usual care sequencing: clinicians commonly prescribe home-based exercises first; office-based therapy supplements or replaces home therapy for patients needing additional instruction, supervision, or who fail to improve.

Typical approach: start with home exercises; add in-office sessions to establish technique, troubleshoot, and reinforce a home program.
In-office visits are often limited to establishing/supporting the home program; published studies indicate usually <12 visits are required for resolution.
Document rationale when deviating from the usual sequencing (e.g., need for direct supervision, poor adherence, or complex clinical presentation).

Symptom assessmentCISS used in trials to quantify symptomatic severity

inv-42: Convergence Insufficiency Symptom Survey (CISS) — scoring and thresholds

CISS description15-item symptom survey with scores 0 (least symptomatic) to 60 (most symptomatic)

Asymptomatic thresholdA score <16 is considered asymptomatic

Clinical improvement thresholdA decrease of ≥10 points is considered improved

inv-43: Normal near point of convergence — definition used in trials

Normal near point of convergence (trial definition)Defined in trials as <6 cm from the nose

Improvement criterionImprovement defined as a decrease of >4 cm from baseline to follow-up

Use in outcome classificationUsed in RCTs to classify normal vs abnormal near point convergence status

inv-44: Normal positive fusional vergence — passing Sheard's criteria and thresholds

Normal positive fusional vergence (trial criteria)Passing Sheard's criteria and having positive fusional vergence blur/break >15 prism diopters

Improvement definitionImprovement defined as an increase of ≥10 prism diopters from baseline to follow-up

Testing methodPFV measured with a prism bar at near; classification may require blur or break values

inv-45: Learning disabilities — examples and required qualified diagnoses

Examples includedAttention deficit disorders, dyslexia, dysphasia, and reading disorders

Diagnostic requirementDiagnoses of learning disabilities should be made by a qualified, licensed professional

Scope notePolicy treats orthoptic training for learning-disability indications as investigational due to insufficient evidence

inv-46: Orthoptic/vision therapy — typical delivery and session course

Typical delivery formatsOffice-based (in‑clinic) vergence/accommodative training with home reinforcement; home-only exercises; computer‑based programs; or combinations

Typical course lengthDelivered over approximately 12 sessions (about 5 weeks) in trials; some protocols extend to 12–16 weeks for weekly visits

Clinical rationaleIn-office therapy is used when home-based therapy fails or when patients require monitoring, anti-suppression strategies, or additional assistance

inv-47: Orthoptic training / vision therapy — definition of modalities (in-office, home, computer)

Definition of modalitiesA set of exercises delivered in-office, prescribed for home practice, or via computer-based programs aimed to improve convergence amplitudes and vergence function

In-office roleSupervised sessions to teach techniques, monitor progress, and provide anti-suppression or additional assistance

Home/computer roleDaily home exercises or computer vergence programs used as reinforcement between in-office visits

inv-48: Home-based therapy — definition and examples (e.g., pencil push-ups)

DefinitionExercises prescribed for patients to perform at home to reinforce orthoptic training (e.g., pencil push-ups)

ExamplesPencil push-ups, prescribed home vergence exercises, and home computer-based vergence programs

Effectiveness noteHome-based therapy may be less effective than supervised in-office therapy unless compliance is closely monitored; trials often used home therapy as comparator