CurrentUnitedHealthcarePolicy CS131TN.P

Visual Information Processing Evaluation and Orthoptic and Vision Therapy (for Tennessee Only)

Policy governing coverage and exclusions for visual information processing evaluation and orthoptic and vision therapy for Medicaid and CoverKids members in Tennessee. It directs users to TennCare Medicaid Chapter 1200-13-13-.10 for medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyVisual Information Processing Evaluation and Orthoptic and Vision Therapy (for Tennessee Only)

Policy CodePolicy CS131TN.P

Change TypeRemoved prior coverage statementclarified TennCare guidance

Effective DateMar 1, 2026

Next Review Date

Key ActionApply TennCare Medicaid Chapter 1200-13-13-.10 to determine medical necessity for these services.

SourceLink

POLICY UPDATE CHANGES

Removed coverage statement

Updated instruction to refer to the TennCare Medicaid, Chapter 1200-13.13-.10: Exclusions for medical necessity clinical coverage criteria for visual information processing evaluation and orthoptic and vision therapy

Updated References section to reflect the most current information

Tennessee-onlyjurisdiction

Medicaid & CoverKidsapplies to

CS131TN.Pidentifier

References updated

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Coverage and Medical Necessity Criteria

Medical necessity source

Covered when ALL of the following are met:

TennCare medical necessity: Providers must apply TennCare Medicaid, Chapter 1200-13-13-.10: Exclusions for visual information processing evaluation and orthoptic and vision therapy to determine medical necessity and coverage

Policy itself does not provide alternate medical necessity criteria; it directs to the referenced TennCare chapter

For determinations of medical necessity and coverage for visual information processing evaluation and orthoptic and vision therapy, refer to TennCare Medicaid, Chapter 1200-13-13-.10: Exclusions for visual information processing evaluation and orthoptic and vision therapy. This policy does not restate alternate medical necessity criteria and directs providers to the referenced TennCare chapter to determine whether services meet coverage requirements.

A prior coverage statement was removed from this policy. As of the 03/01/2026 revision, providers should note that services may be non-covered if they fall within the exclusions set forth in TennCare Medicaid, Chapter 1200-13-13-.10. The policy now redirects medical necessity and coverage determinations to that TennCare chapter rather than maintaining an internal coverage statement.

Procedure Codes and Coding References

Procedure codes referencedCPT

0687T	Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session.
0688T	Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month.
0704T	Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment.
0705T	Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days.
0706T	Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month.
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.

Procedure codes referenced (duplicate group for exact split)CPT

0687T	Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session.
0688T	Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month.
0704T	Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment.
0705T	Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days.
0706T	Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month.
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.

Provider Actions, Prior Authorization, and Billing Notes

Prior Authorization

Prior authorization and code reference

Refer to TennCare Medicaid, Chapter 1200-13-13-.10 for medical necessity determinations; the listed procedure codes are provided for reference only and their inclusion does not imply coverage or guarantee payment.

Procedure codes referenced in this policy: 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92066 (reference only).

Step Therapy

Step therapy governance

This policy is informational and does not establish step therapy requirements. Follow applicable contractual and state program rules when determining any step therapy obligations.

Background and Context

Vision therapy and orthoptic training are clinical procedures rather than FDA-regulated therapies; some devices and digital programs used in vision training have varying FDA statuses. Providers should rely on clinical and state coverage rules (see TennCare Chapter 1200-13-13-.10) when determining whether device-assisted or software-based vision therapy services are covered.

Definitions

Vision therapy / orthoptic training — definitions and delivery modes

DefinitionProcedures and device-assisted programs intended to improve visual functions such as amblyopia and binocular vision; may be delivered in-person or remotely and can involve software or eye-tracking devices.

Delivery modesIn-person therapy, remotely delivered programs (home use with device or software), and supervised telehealth sessions.

Device types referencedEye‑tracking systems, head‑mounted display (HMD) compatible software, and software-only digital therapeutics used for amblyopia treatment.

Regulatory noteVision therapy is a procedure (not regulated as a procedure by FDA); devices and digital therapeutics used in training programs may have varying FDA statuses (510(k), De Novo, or exemptions).

Examples of FDA‑cleared/regulated productsCureSight (eye‑tracking system cleared for amblyopia), Luminopia One (De Novo software for HMDs), RevitalVision/NeuroVision AA‑1 (510(k) clearance).