ModifiedUnitedHealthcarePolicy CS131LAM

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

This Louisiana-specific UnitedHealthcare medical policy governs coverage and medical necessity determinations for orthoptic therapy/vision therapy, occlusion and pharmacologic penalization for amblyopia, prism adaptation therapy, and visual information processing evaluations and digital/remote therapies for amblyopia for members in Louisiana.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS131LAM

Change TypeDefinitions updatedprevious version archived

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionWhen prescribing device-based digital therapies, document FDA clearance status, indication, dosing plan, baseline visual measures, and adherence/safety monitoring for authorization.

SourceLink

POLICY UPDATE CHANGES

Updated definition of "Vision Restoration Therapy (VRT)".

Archived previous policy version CS131LAL.

3Proven therapy types listed

5+Unproven / not medically necessary

Several RCTsEvidence for amblyopia

FDA-clearedDigital amblyopia devices cited

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

CS131LALPrevious version

Coverage and Medical Necessity Criteria

inv-01: Proven / Medically Necessary Indications

Covered when ALL of the following are met:

Covered indications: Orthoptic Therapy or Vision Therapy is considered proven and medically necessary for treating Convergence Insufficiency; Occlusion Therapy or Pharmacologic Penalization Therapy is considered proven and medically necessary for treating Amblyopia; Prism Adaptation Therapy is considered proven and medically necessary for treating Esotropia.

From Coverage Rationale

inv-02: Unproven / Not Medically Necessary

The following therapies are considered unproven and not medically necessary due to insufficient evidence of efficacy:

Unproven / Not Medically Necessary: Virtual perception therapy for treating learning or language disorders; Orthoptic Therapy or Vision Therapy for indications other than Convergence Insufficiency; Vision Restoration Therapy for visual field deficits after stroke or neurotrauma; Remote, online, and/or digital therapy for Amblyopia; Visual information processing evaluation to diagnose reading or other learning disabilities.

From Coverage Rationale and evidence summaries

inv-03: Amblyopia - Supported Treatments and Dosage Guidance

Amblyopia treatments with comparative evidence and usage guidance:

Amblyopia - occlusion and pharmacologic penalization: Conventional occlusion (patching) and atropine penalization are both effective for improving amblyopic eye visual acuity; atropine may have better adherence and different adverse event profiles; combined atropine plus patching (CAPT) showed small but statistically greater VA improvement than patching alone in one RCT. When residual amblyopia persists after 2 hours daily patching, increasing to 6 hours daily produced greater improvement in VA after 10 weeks.

Summarized from multiple RCTs and systematic reviews

inv-04: Study eligibility and dosing (informational)

Study-based eligibility and dosing examples (informational):

CureSight pivotal trial eligibility and dosing: Children aged 4 to <9 years with anisometropic, small-angle strabismic, or mixed-mechanism amblyopia; device dosing 90 minutes/day, 5 days/week for 16 weeks (120 hours).age 4-<9; 120 hours total

Noninferior to patching in VA improvement; higher adherence reported

Phase 3 dichoptic therapeutic example: Phase 3 dichoptic device trial: children aged 4–7 years used device 1 hour/day, 6 days/week for 12 weeks; primary outcome change in amblyopic eye VA at 12 weeks.1 hr/day x 6 days/week x 12 weeks

Significant improvement vs glasses-only comparison

Dichoptic movie/game dosing used in smaller trials: Examples from smaller trials include dichoptic movie or game regimens ranging from 30–120 minutes per day, several days per week, with total durations reported from 2 to 16 weeks; dosing and adherence were heterogeneous across studies.

inv-05: Evidence summaries and comparative outcomes

Summaries of clinical efficacy findings from key trials and reviews:

Prism adaptation (PA) overall effect: The Prism Adaptation Study (PAS) multicenter RCT (n=333) found higher surgical success for participants who underwent the PA process versus no PA (overall 83% vs 72% success at 6 months); PA responders given augmented surgery had the highest success (89%).

Supports PA process improving surgical outcomes in acquired esotropia

Office-based vergence/accommodative therapy (OBVAT) for CI: Cochrane/NMA and the Convergence Insufficiency Treatment Trial (CITT) trials show that office-based vergence/accommodative therapy with home reinforcement significantly improves motor outcomes (NPC, PFV) and increases the chance of a successful outcome versus home-based therapies or placebo; symptomatic improvement findings are less consistent.

High‑certainty evidence for motor outcomes in children; evidence in adults less clear

Orthoptic/vision therapy for strabismus: Available RCTs and meta-analyses for exotropia/esotropia report short-term improvements in control or binocular function in some studies (including post-operative VR training), but overall evidence quality is limited and heterogeneous, and larger long-term trials are needed.

inv-06: Evidence summaries by indication

Summaries of trial and review findings by indication that inform coverage decisions:

Pediatric esotropia with amblyopia: An RCT (Liang et al. 2023) found binocular vision training (BVT) combined with Fresnel press-on prism (FPP) produced greater improvements in VA, binocular function, and higher strabismus cure rates compared with prism alone (cure rates 87.5% vs 30.2%); study limited by small sample size.

Supports potential benefit of combined BVT+FPP in selected pediatric esotropia with amblyopia

Postoperative VR training for strabismus: An RCT (Zhang et al. 2023; n=200) reported that early postoperative VR training improved orthophoria rates, reduced regression, and increased simultaneous vision and distant stereovision at 6 months versus no training.

Suggests benefit of VR rehabilitation after strabismus surgery

Part-time patching for intermittent exotropia (IXT): Systematic reviews and RCTs indicate part-time occlusion (PTO) or patching can improve motor alignment and control compared with observation in children with IXT; evidence is limited by heterogeneity and small sample sizes.

Patching shows benefit vs observation in some pediatric IXT populations

inv-07: Evidence-based care priorities and limitations

Guideline-aligned care priorities, evidence stance and limitations:

Amblyopia standard of care: Initial management should correct refractive error and consider patching or pharmacologic penalization (e.g., 2 hours daily patching for moderate amblyopia) before considering adjunctive perceptual or device-based vision therapies; monitor for recurrence after treatment cessation.

AAO/AAPOS/AAP guidance summarized

VT and therapies for learning disabilities: Behavioral vision therapy, eye muscle exercises, training glasses, prisms, and colored lenses/filters are not supported as treatments for dyslexia or learning disabilities per joint guidance and should not be used for that indication.

AAP/AAO/AAPOS/AACO joint statement

VT, VRT, and perceptual learning for neurologic visual deficits: Small RCTs and pilot studies report some positive within-group signals for VR or perceptual learning for post-stroke deficits, but evidence is inconsistent and limited; these approaches are best considered experimental/limited evidence pending larger trials.

Evidence quality low to moderate; further studies needed

inv-08: Therapy sequencing and modality selection

Covered when ALL of the following are met (clinical sequencing and modality selection):

Initial conservative management

Examples of standard amblyopia therapies: Patching, pharmacologic penalization (eg, atropine), and full-time refractive correction.
Clinical examples

Escalation to surgery or adjunctive procedures: If eyeglasses and amblyopia management do not align esotropic eyes or achieve target binocular function, surgical correction may be indicated; amblyopia treatment is usually initiated before surgery.

AAO esotropia guidance

Preference for office-based VT when indicated: When evidence supports therapist involvement (eg, convergence insufficiency), office-based vergence/accommodative therapy with home reinforcement is preferred over home-only programs due to higher demonstrated efficacy.

CITT and Cochrane NMA evidence

Visual information processing evaluations performed specifically to diagnose reading disorders or other learning disabilities are listed in this policy as unproven and not medically necessary. The policy states these tests lack sufficient evidence linking test findings to causation or to effective treatments for dyslexia or related learning disabilities and therefore should not be used alone to establish a learning-disability diagnosis.

Vision Restoration Therapy (VRT) — defined here as an in‑home, computer‑based program intended to strengthen residual visual processing after neurologic injury — is listed as unproven and not medically necessary for treating visual field deficits after stroke or neurotrauma. The policy notes only limited quality clinical evidence is available and that results from small or heterogeneous studies do not support routine use for post‑stroke field loss.

A 2021 systematic review and meta‑analysis concluded that existing randomized trials of binocular (dichoptic) therapies are heterogeneous and do not provide consistent evidence that binocular treatment can replace conventional patching. The meta‑analysis highlighted high between‑study heterogeneity, inconsistency of results, and the absence of robust evidence to support binocular therapy as a standalone alternative to patching.

The policy indicates no well‑designed clinical trials were identified evaluating vision therapy for convergence excess, divergence excess/insufficiency, or for nystagmus in the excerpts reviewed. This absence of rigorous trial data limits the ability to conclude efficacy for these indications.

A meta‑analysis of prism adaptation (PA) trials for unilateral post‑stroke neglect found no significant short‑ or long‑term benefit compared with sham or no treatment; based on these pooled results the policy states routine or practice‑wide use of PA for post‑stroke neglect is not supported by the evidence.

Professional society statements cited in the policy explicitly indicate that behavioral vision therapy, eye muscle exercises, training glasses, prisms, and colored filters/lenses are not supported as treatments for dyslexia or learning disabilities. The joint guidance concludes these modalities lack valid scientific evidence of benefit for learning disorders and are not endorsed for that purpose.

The guideline summary noted in the policy states that routine, comprehensive professional eye examinations for normal, asymptomatic children have no proven medical benefit. Screening and targeted referral for children who fail vision screening or are at higher risk remain recommended, but routine full exams in asymptomatic children are not shown to improve outcomes.

This medical policy is provided for informational purposes and must be applied in the context of the member’s specific benefit plan. Coverage determinations should reference applicable federal, state, or contractual benefit terms because plan provisions may override or differ from the policy; the policy itself does not constitute medical advice.

Remote, online, or digital therapies for amblyopia (including telehealth or device‑delivered programs) are considered unproven and not medically necessary in this policy due to limited and inconsistent quality of evidence. Small trials, short follow‑up, and high dropout rates are cited as reasons the evidence is insufficient to support routine coverage of remote/digital amblyopia therapy.

Orthoptic Therapy or Vision Therapy used for indications other than convergence insufficiency is listed as unproven and not medically necessary. The policy limits proven coverage to specific indications and therefore does not support routine use of orthoptic/vision therapy for other disorders without higher‑quality evidence.

Some randomized trials reported minimal or inferior responses to binocular/dichoptic treatments compared with conventional patching; for example, an RCT of adolescents found patching led to greater visual‑acuity gains than a binocular tablet game, though poor adherence in the binocular arm may have contributed. Such trial results are cited as evidence that binocular treatments are not consistently superior and may be insufficient alone in some populations.

The policy summarizes the evidence for orthoptic/vision therapy in exotropia as limited and inconclusive. Publications are characterized by post‑hoc analyses, short follow‑up, and inconsistent results, so the evidence does not firmly establish effectiveness for exotropia.

Systematic reviews and meta‑analyses of post‑stroke interventions report heterogeneous study designs, small samples, and low‑to‑very‑low quality evidence. The policy indicates there is inadequate evidence to support routine use of immersive virtual reality or other restitutive interventions (including some VRT approaches) for post‑stroke visual field defects and perceptual disorders; these should be considered experimental or investigational pending higher‑quality trials.

Vision therapy modalities specifically marketed for dyslexia or other learning disabilities (behavioral/perceptual VT, colored filters/lenses, training glasses) are identified as lacking convincing evidence of efficacy and are therefore not supported as treatments for learning disabilities.

The American Optometric Association guidance, as cited in the policy, notes that home‑based vision therapy alone has insufficient supporting data and may be less effective than office‑based therapy with therapist involvement. Accordingly, the policy states that exclusive home‑based VT has limited evidence and may not achieve the outcomes reported for supervised, office‑based programs.

Provider Requirements, Prior Authorization, and Documentation

Billing Rule

Reference to applicable procedure codes and coverage caveat

Providers must document the applicable procedure codes on claims and note that codes for telehealth, remote, or digital amblyopia/orthoptic therapies (starred above) may be subject to plan, state, or contractual coverage caveats. Listing of a code is for reference only and does not imply coverage or guarantee payment.

Reference the starred device/digital CPT-like codes when billing remote/digital amblyopia therapies; verify benefit plan terms before authorization or claim submission.
Inclusion of a code in this policy does not imply that the service is covered; federal, state, or contractual plan terms govern benefits.

Prior Authorization

Device-based amblyopia therapy — prior authorization information

Procedure Codes and Billing References

CPT / Proprietary Codes (reference)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 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
92499	Unlisted ophthalmological service or procedure

Definitions

Amblyopia — definition

DefinitionAmblyopia: decreased vision in one or both eyes due to abnormal visual development in infancy and childhood; poor image from one eye leads to inadequate stimulation of neural pathways.

Typical clinical noteOften results from anisometropia, strabismus, or form deprivation and is preventable/treatable in childhood; untreated leads to permanent changes.

Common treatments referencedOcclusion (patching) and pharmacologic penalization (atropine) to promote use of the amblyopic eye.

Convergence Insufficiency — definition

DefinitionConvergence Insufficiency: inability to maintain binocular function while working at near distance; typically one eye may turn outward (intermittent exotropia) when focusing at near.

Assessment measures

Clinical Background and Rationale

Amblyopia is defined in the policy as reduced visual acuity resulting from abnormal visual development in infancy and childhood. Common, evidence‑based treatments include occlusion (patching) and pharmacologic penalization (atropine), which remain standard therapies to improve the amblyopic eye’s visual acuity.

Policy Revision History

2025-05-01RevisionLatest

Definitions updated: the definition of 'Vision Restoration Therapy (VRT)' was revised and supporting sections (Clinical Evidence, FDA, References) were updated; previous policy version CS131LAL archived.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS131LAM

Change TypeDefinitions updatedprevious version archived

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionWhen prescribing device-based digital therapies, document FDA clearance status, indication, dosing plan, baseline visual measures, and adherence/safety monitoring for authorization.

SourceLink

On This Page

Heterogeneous dosing and adherence; some trials reported short-term VA gains

Heterogeneous results across studies

VT for post-stroke visual/perceptual deficits: RCTs and systematic reviews of VT, VR, and perceptual learning for post-stroke visual field defects or neglect report mixed or limited between-group benefits; within-group improvements are sometimes reported but overall evidence quality is low to moderate.

Routine use not supported by strong consistent RCT evidence

Use of FDA‑cleared digital therapeutics as adjuncts: FDA‑cleared device-based digital therapies (eg, CureSight for ages 4 to <9; Luminopia One for ages 4–7) may be used as adjuncts to full-time refractive correction when prescribed by a trained eye‑care professional and when trial evidence or regulatory clearance supports use in the indicated age/condition.

FDA informational guidance

Device-based amblyopia therapies (including FDA-cleared eye-tracking systems and software-based digital therapeutics) may require prior authorization depending on the member's benefit plan. When prior authorization is required, submit documentation demonstrating indication, device FDA clearance status (if available), trial treatment protocol, prescribed dosing, and objective adherence data.

Examples of trial-defined dosing to support authorization requests: CureSight (eye-tracking): 90 minutes/day, 5 days/week for 16 weeks (120 hours) as used in pivotal RCT.
Examples: Dichoptic digital therapeutics: ~1 hour/day, 6 days/week for 12 weeks as used in phase 3 RCTs.
Include device description, manufacturer, FDA clearance/510(k) reference (if available), and plan for monitoring adherence and response.

Note

Prior authorization not specified in excerpt

Some portions of the source evidence and excerpts did not specify explicit UnitedHealthcare-wide prior authorization rules. Providers should consult the member's benefit plan and payer-specific prior authorization requirements in addition to this policy.

This policy excerpt does not itself define universal payer prior authorization mandates — check the member's federal/state/contractual benefit plan and UnitedHealthcare prior authorization resources.
When in doubt, contact UnitedHealthcare provider services or use the plan's authorization portal.

Prior Authorization

Prior authorization recommended for VT interventions

Prior authorization is advisable or recommended when Vision Therapy (VT) or device-based/digital therapies are proposed for indications with limited or emerging evidence (e.g., amblyopia digital therapeutics, perceptual learning programs), when combined/complementary therapies are used, or when a device will be supplied for home use. Authorization requests should include clinical rationale and prior conventional therapy attempts when applicable.

Recommend authorization when VT is proposed for strabismus correction, post-stroke rehabilitation, or use in combination with other novel therapies.
Authorization recommended for digital/device therapies intended for home use or billed with device-supply codes (0687T, 0704T).

Prior Authorization

Prior authorization advisable for experimental or limited‑evidence interventions

Prior authorization is advisable for experimental, investigational, or limited‑evidence interventions (e.g., vision restoration therapy, RevitalVision/perceptual learning programs for amblyopia, interventions marketed for learning disabilities) to ensure clinical appropriateness and that plan benefits allow coverage.

Interventions listed as unproven or lacking robust evidence should be reviewed via prior authorization when coverage is requested.
If considered for compassionate or off-label use, include objective baseline measures, justification why conventional treatments are inadequate, and a defined outcome assessment plan.

Documentation Required

Device-based digital therapy — documentation for authorization

For device-based digital therapies, authorization documentation should include device regulatory status (FDA clearance/510(k) when present), pivotal trial evidence summary, prescribing instructions (frequency/duration), and adherence reporting plan. Objective device-captured adherence data should be included in follow-up authorization/continuation requests.

Provide FDA clearance or 510(k) reference if available (e.g., CureSight; Luminopia One) and device labeling indications.
Summarize supporting clinical trial data, specify prescribed dosing (hours per day, days per week, total duration), and include plan for collecting device adherence data and clinical follow-up.

Note

Use of utilization review tools

UnitedHealthcare may use third‑party utilization review tools (for example, InterQual) to assist in benefits administration and preauthorization determinations. Providers should expect requests for standard elements required by such tools (clinical notes, prior treatments, objective measures).

Anticipate utilization review requests consistent with InterQual or equivalent guidance.
Include required clinical documentation to facilitate timely review.

Denial Risk

Denial risks for unproven services

Services or therapies identified in this policy as unproven, experimental, or not medically necessary may be denied. Denial risk increases when submitted documentation lacks objective adherence data, has short follow-up, or lacks comparative evidence to standard treatments.

Common denial triggers: missing objective adherence monitoring for device therapies; short follow-up or early stopping of trials; inadequate comparative evidence vs. standard treatments (patching/atropine/surgery).
Interventions marketed for learning disabilities or dyslexia (behavioral/perceptual VT, colored lenses/filters) are unsupported and at high risk for denial.

Denial Risk

Evidence limitations that could trigger denial

Key evidence limitations that may lead to denial include lack of objective adherence monitoring, small sample sizes, short follow‑up durations, early trial stoppage, absence of active/sham comparators, and inconsistent results across trials and meta-analyses.

Authorization/coverage requests lacking robust comparative evidence (e.g., several small RCTs without long-term follow-up) are vulnerable to denial.
Include longer-term outcome data and objective adherence metrics when available to mitigate these limitations.

Note

Not present in this excerpt: no explicit prior authorization/billing rules

Not all operational or payer-specific prior authorization rules are present in this excerpt of the source material. Providers must confirm UnitedHealthcare and plan‑specific prior authorization and billing rules before delivering or billing services.

This policy provides clinical context but does not replace payer authorization portals or plan documents.
Contact UnitedHealthcare or check the member’s benefit plan for specific PA requirements.

Denial Risk

Lack of demonstrated clinical effect for non‑surgical treatment

The literature shows limited or no demonstrated clinical effect for many non‑surgical treatments for intermittent exotropia and other forms of strabismus in terms of long‑term alignment outcomes. Non-surgical options may have limited impact on angle of deviation compared with surgery.

Non-surgical interventions (orthoptic exercises, occlusion, prisms, over-minus lenses) often show limited or inconsistent impact on angle of deviation or long-term control compared with surgical options.
Document prior conservative therapy attempts and clinical rationale if surgery is deferred.

Denial Risk

Unsupported treatments for learning disabilities

Interventions claiming to treat learning disabilities (e.g., behavioral/perceptual vision therapy, visual information processing evaluations as diagnostic tools for dyslexia) are unsupported by guideline bodies and carry high denial risk. Document referral to appropriate educational/neurological evaluations when these conditions are suspected.

Behavioral/perceptual VT, colored lenses/filters, and visual training marketed for dyslexia or learning disabilities are not endorsed by major professional societies and are considered unsupported for treating LD.
When vision screening identifies visual impairment in children with learning concerns, document referrals for comprehensive ophthalmologic and multidisciplinary educational/psychological evaluation.

Note

Reference contractual requirements; plan terms override policy

All coverage decisions must be made in the context of federal, state, and contractual plan terms. This Medical Policy provides guidance but does not override specific benefit plan provisions.

Verify member benefits and any state/federal mandates before authorizing or billing services.
Policy guidance is informational and subordinate to the member’s contractual coverage terms.

Documentation Required

Documentation expectations

Providers should document clinical indications, prior and concurrent therapies, and the specific type of therapy being delivered (in‑office VT, home-reinforcement, device-based digital therapy, or remote supervision). Clear documentation expedites review and reduces denial risk.

Specify indication (e.g., amblyopia type, strabismus subtype), prior treatments (patching/atropine/surgery), and rationale for proposed VT or device therapy.
Indicate whether therapy is office‑based, home‑based with device, or remote/telehealth, and include treatment plan and monitoring approach.

Documentation Required

Required clinical documentation

Authorization requests should include required clinical documentation elements: baseline clinical measures, objective adherence data (for device therapies), treatment protocol (frequency/duration), and prior conventional therapy attempts or contraindications.

Baseline and follow‑up visual acuity, angle of deviation (prism diopters), stereoacuity, diplopia questionnaires, and control/near scores where applicable.
For device/digital therapies include device adherence logs, automated usage reports, technical support records, and clinician interpretation of device data.

Documentation Required

Clinical measurement documentation

Document objective clinical measurements at baseline and during follow-up to establish medical necessity and response to therapy. These measures are essential for preauthorization and continuation requests.

Baseline measures: best-corrected visual acuity (BCVA), angle of deviation (prism diopters), stereoacuity, refractive status, control scores (e.g., NCS), and diplopia questionnaires.
Follow-up measures: repeat BCVA, stereoacuity, alignment measurements, adherence data, and adverse events monitoring at defined intervals matching the treatment protocol.

Documentation Required

Baseline and follow-up clinical measures

Baseline and follow‑up measures to include in requests or clinical records: alignment (prism diopters), control scores (e.g., NCS), stereoacuity measurements, refractive correction status, diplopia frequency/severity (DQ), and objective adherence data for device therapies.

Alignment: alternate cover test and prism measures at distance and near.
Function: stereoacuity (Titmus, Randot), diplopia questionnaire scores, and control assessments.
Adherence: device-captured usage reports or documented home exercise logs.

Documentation Required

Documentation for visual information processing evaluations

When visual information processing evaluations are performed, document the specific tests used, the results, and how findings relate to academic or functional impact. These evaluations alone are not diagnostic of learning disabilities and should be integrated into multidisciplinary assessments.

Record which VIPE tests were administered (e.g., VMI, DEM), raw and standardized scores, and interpretation relative to academic performance.
Include referrals and recommendations for educational, psychological, or ophthalmologic follow-up when VIPE suggests deficits.

Note

Plan terms override policy

Always reference the applicable federal, state, and contractual benefit plan terms when making coverage decisions. This policy does not replace plan-specific rules, and plan terms take precedence.

Before authorizing or providing services, confirm member coverage, state mandates, and any plan exclusions or limits.
UnitedHealthcare reserves the right to modify policies and to use third‑party criteria in benefit determinations.

Step Therapy

Consideration of conventional therapy before device therapy

Conventional therapies (refractive correction, patching, pharmacologic penalization) should generally be considered or documented as tried or addressed before escalating to device-based or novel VT unless there is a clear clinical rationale to proceed directly to a device intervention.

Document attempts at refractive correction and standard amblyopia treatments (patching, atropine) prior to device/digital therapy when clinically appropriate.
If device therapy is proposed first-line, include rationale why conventional therapy is inappropriate or contraindicated.

Note

Evidence discusses sequence of prism → surgery

Evidence and clinical trials discuss the sequence of prism adaptation prior to augmented or modified strabismus surgery; prism adaptation can inform surgical planning and has been shown to improve surgical outcomes in selected patients.

When prism adaptation is used, document the prism-adapted angle and whether surgery will be conventional or augmented based on prism response.
Prism adaptation may lead to higher success rates when used to guide augmented surgery — include prism response data in surgical authorization requests.

Step Therapy

Conservative therapies as steps before novel VT

Conservative therapies (spectacles, occlusion/penalization, over‑minus lenses, prisms, exercises) are commonly used steps prior to novel VT for conditions such as intermittent exotropia and amblyopia; document these attempts and their outcomes when seeking authorization for additional/novel therapies.

Include duration and objective response to conservative measures (e.g., change in control score, stereoacuity, angle of deviation) in authorization submissions.
Highlight compliance data if poor adherence to conservative therapy is the rationale for escalation.

Clinical measures include near point of convergence (NPC), positive fusional vergence (PFV), and symptom surveys (CISS).

Evidence-based therapyOffice-based vergence/accommodative therapy with home reinforcement improves motor outcomes versus home-only approaches (high-certainty evidence in children).

Orthoptic Therapy / Vision Therapy — definition

DefinitionOrthoptic Therapy / Vision Therapy: clinician‑directed series of supervised in‑office exercises with home reinforcement over weeks to months intended to improve binocular function, oculomotor control, and visual skills; does not include refractive treatment.

Typical componentsMay include exercises, training glasses, prisms, patches, electronic targets, and home practice assigned by the therapist.

Evidence stanceOBVAT plus home reinforcement is superior to home-based therapies for convergence insufficiency in children; evidence for other indications is limited or mixed.

Pharmacologic Penalization (Atropine) — definition

DefinitionPharmacologic Penalization (Atropine): instillation of drops (eg, atropine) to blur the better‑seeing eye and encourage use of the amblyopic eye.

Clinical roleAn alternative to patching for amblyopia; may have different adherence and adverse‑event profiles and can be combined with patching in some trials.

Guidance from trialsComparative trials and meta‑analyses show atropine and patching both improve amblyopic eye VA; combined atropine+patching showed slightly greater VA improvement in one RCT.

Prism Adaptation Therapy — definition

DefinitionPrism Adaptation Therapy: use of prisms (clear triangular prisms) to bend light and align visual axes, simulate absence of strabismus, reveal latent deviation, and assist with surgical planning or prism prescription.

Diagnostic usePrism adaptation test (PAT) can reveal 'true' angle of deviation and produce dose‑relevant angle changes that inform surgical dosing.

Therapeutic rolePrism wear may control diplopia in some adults and is used as initial or adjunctive therapy; PAS RCT showed PA process improved surgical success rates versus no PA.

Vision Restoration Therapy (VRT) — definition

DefinitionVision Restoration Therapy (VRT): an in‑home computer‑based program intended to strengthen residual visual information processing after neurologic injury (stroke, TBI, tumor) to improve visual field deficits.

Typical deliveryHome‑based software exercises administered over weeks to months; some studies combine VRT with adjuncts (eg, tDCS).

Evidence stanceEvidence is limited and conflicting; studies report within‑group improvements but between‑group effects and methodological quality are inconsistent, so routine use is not well supported.

Binocular/dichoptic digital therapy — definition

DefinitionBinocular/dichoptic digital therapy: home‑based or supervised treatments that deliver different visual input to each eye (games, videos, eye‑tracking devices) to rebalance contrast and encourage binocular combination and improve amblyopic eye visual acuity and stereoacuity.

Examples and dosingExamples include CureSight (90 min/day, 5 days/week for 16 weeks) and phase‑3 dichoptic devices (1 hr/day, 6 days/week for 12 weeks); trial dosing is heterogeneous across studies.

Evidence stanceSome RCTs show noninferiority or superiority to patching in short‑term VA gains and high adherence, but meta‑analyses note heterogeneity; remote/digital therapies are considered unproven or limited in some policy contexts pending further evidence.

Prism Adaptation Test (PAT) — definition

DefinitionPrism adaptation test (PAT): a diagnostic/therapeutic method using prisms to reveal latent angle of deviation and guide surgical planning or prism prescription in esodeviations.

UtilityPAT can cause dose‑relevant changes in angle of squint and is considered essential in preoperative assessment for certain decompensated esophoria and microesotropia cases.

Study findingsRetrospective and prospective studies report significant angle changes with PAT and recommend its use to determine 'true' AOS prior to surgery.

Prism Adaptation (PA/PAT) — definition

DefinitionPrism Adaptation (PA/PAT): clinical process of prescribing prism lenses to neutralize deviation, assessing motor stability and sensory fusion, and using prism‑adapted angles to guide surgical dosing or as primary therapy.

Outcomes evidencePAS multicenter RCT found overall higher surgical success with PA process (83% vs 72%); PA responders given augmented surgery had highest success (89%).

LimitationsObservational studies demonstrate variability in long‑term motor success and weaning rates; patient selection and latent deviation size affect outcomes.

Office-based vergence/accommodative therapy (OBVAT) — definition

DefinitionOffice‑based vergence/accommodative therapy (OBVAT): therapist‑administered in‑office sessions with home reinforcement exercises aimed at improving convergence and accommodation measures such as near point of convergence (NPC) and positive fusional vergence (PFV).

EvidenceCochrane NMA and the CITT RCT demonstrate OBVAT plus home reinforcement significantly improves motor outcomes and increases chance of successful outcome versus home‑based therapies in children.

Typical courseUsually delivered weekly over several months with prescribed home exercises; success rates in trials reported near 75% in children at 12 weeks for OBVAT.

CISS — Convergence Insufficiency Symptom Survey definition

DefinitionCISS: Convergence Insufficiency Symptom Survey — a patient‑reported outcome measuring symptoms related to convergence insufficiency.

UseUsed in clinical trials and practice to quantify symptom burden and assess treatment response for CI.

ContextOften paired with clinical measures (NPC, PFV) to define successful outcome in CI trials.

Intermittent Exotropia (IXT) — definition

DefinitionIntermittent Exotropia (IXT): a form of exotropia where outward deviation occurs intermittently; outcomes often assessed by angle of deviation, control scales, and stereoacuity.

Treatment contextConservative measures studied include patching, over‑minus lenses, prisms, and observation; patching shows benefit versus observation in some pediatric populations.

Evidence limitationsRCTs and meta‑analyses show heterogeneity and limited long‑term data, so evidence for orthoptic/VT in IXT is limited or inconclusive.

Visual Field Defect (VFD) — definition

DefinitionVisual Field Defect (VFD): loss of part of the visual field commonly after stroke or neurologic injury, measured with Humphrey visual field testing and quantified by perimetric mean deviation (PMD).

Rehabilitation approachesInterventions studied include motion discrimination training, VR‑based perceptual learning, and VRT; some within‑group improvements reported but between‑group effects inconsistent.

Evidence stanceSystematic reviews and RCTs report limited or mixed quality evidence for restitutive and VR‑based interventions for post‑stroke VFDs; routine use is not well supported.

Vision Therapy (VT) / Orthoptic Therapy — definition

DefinitionVision Therapy (VT) / Orthoptic Therapy: clinician‑directed exercises and interventions intended to improve oculomotor control, binocular vision, and visual perceptual skills; used for convergence insufficiency, amblyopia adjunctively, or post‑neurologic rehabilitation.

ComponentsMay combine in‑office therapist sessions with home reinforcement; tools include prisms, filters, training glasses, electronic targets, and balance tasks.

Evidence summaryStrongest evidence supports OBVAT for CI; evidence for other indications (strabismus subtypes, post‑stroke rehabilitation) is limited or mixed.

Vision Restoration Therapy (VRT) — alternate definition

DefinitionVision Restoration Therapy (VRT): computer‑based training aiming to stimulate residual vision or border zones of visual field defects to improve detection sensitivity and visual field function; defined as an in‑home program for rehabilitation after neurologic injury.

Updated policy notePolicy definitions were updated 05/01/2025 to revise the VRT definition and supporting clinical evidence sections.

Evidence stanceOverall evidence is limited and conflicting; pilot studies and case series report improvements but lack controlled, generalizable data.

Amblyopia — duplicate/alternate definition (inventory)

DefinitionAmblyopia: decreased visual acuity in one or both eyes due to abnormal visual development in infancy/childhood resulting from inadequate neural stimulation from the affected eye(s).

Prevention/timingTimely treatment in childhood is critical; untreated amblyopia leads to permanent structural brain changes and reduced visual function.

Screening implicationPreschool vision screening aims to identify amblyopia risk factors (eg, high refractive error, anisometropia) which should be considered medical conditions warranting evaluation.

Esotropia — definition

DefinitionEsotropia: inward misalignment of one or both eyes (a form of strabismus) that may be intermittent or constant and can occur at near or distance fixation.

Associated managementTreatment options include refractive correction, amblyopia therapy, prism therapy, bifocals, extraocular muscle surgery, botulinum toxin, and pharmacologic agents; amblyopia therapy is usually started before surgery.

Clinical aimRe‑establish binocular alignment as soon as possible to maximize binocular potential and reduce lifetime need for additional surgeries.

Vision Restoration Therapy (VRT) — updated definition entry

DefinitionVision Restoration Therapy (VRT) — updated entry: computer‑based programs intended to stimulate residual vision after neurologic injury to improve detection and visual field function; delivered in‑home and sometimes combined with adjunctive modalities.

Revision notePolicy revision 05/01/2025 updated the VRT definition and supporting clinical evidence and FDA/reference sections.

Evidence summaryClinical evidence remains limited and conflicting with small pilots and case series; larger, controlled trials are necessary to establish effectiveness.