Visual Information Processing Evaluation and Orthoptic and Vision Therapy (for North Carolina Only)
This policy governs coverage and medical necessity for orthoptic therapy/vision therapy, occlusion and pharmacologic penalization for amblyopia, prism adaptation therapy for esotropia, and visual information processing evaluations in North Carolina members under UnitedHealthcare.
Added notation to indicate CPT codes 0687T, 0688T, 0704T, 0705T, 0706T, 92066, and 92499 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program.
Updated Supporting Information, Clinical Evidence and References sections to reflect the most current information.
Coverage Criteria and Evidence-based Indications
inv-01: Medically necessary indications
Covered when specific conditions are met for these indications
Supported by Cochrane and multiple RCTs and long-term follow-up showing comparable efficacy for patching and atropine (chunks 22,24,25).
Evidence from randomized trials demonstrates objective improvements in accommodative amplitude, facility, NPC and PFV with OBVAT (chunks 55-58).
Described as a proven medically necessary therapy for esotropia (chunk 3).
inv-02: Unproven / Not medically necessary
Not medically necessary / unproven services
Listed as unproven or not medically necessary due to insufficient or conflicting evidence (chunk 3).
inv-03: Standard occlusion and pharmacologic penalization — Covered when ALL of the following are met
Covered when ALL of the following are met
Cochrane review found atropine as effective as occlusion; PEDIG and other trials define age ranges and outcomes (chunks 22,25).
inv-04: Escalation of patching dose for stable residual amblyopia
Covered when ALL of the following are met
PEDIG RCT (n=169) showed greater VA improvement at 10 weeks with escalation to 6 hours/day (chunks 24).
inv-05: Comparative therapy selection — Consider when ONE or more of the following apply
Consider when ONE or more of the following apply
NMA of 23 studies (n=3,279) found comparable efficacy across modalities; individual trials and systematic reviews provide context for choice (chunks 20,18,22).
inv-06: Home binocular/digital (e.g., CureSight, dichoptic gaming, VR, Luminopia) — Covered with criteria and documentation when ALL of the following are met
Covered with criteria and documentation when ALL of the following are met
Pivotal CureSight RCT enrolled children 4 to <9 years; prior therapy documentation recommended (chunks 32,31).
Trial regimens and durations are prespecified in RCTs and should guide prescribing (chunk 32).
Trials reported higher adherence with some devices but durability beyond trial follow-up is limited; document adherence and follow-up (chunks 31-33).
Device use should be documented per device/pivotal trial parameters and manufacturer instructions (chunk 31).
inv-07: Evidence summary — efficacy and utility
Evidence summaries and outcomes reported in randomized and nonrandomized studies
Phase 3 dichoptic RCTs and smaller RCTs demonstrate benefit in some settings but systematic reviews report heterogeneity and limited long-term data (chunks 40,39,41,31-33).
Yeh et al. and Park et al. highlight methodological limitations and mixed outcomes (chunks 36,84,85).
Prism adaptation described with supportive cohort and trial evidence for esotropia management (chunks 48,53,62).
inv-08: Office-based vergence/accommodative therapy (OBVAT) — Evidence-supported scenarios
Evidence-supported scenarios where office-based vergence/accommodative therapy (OBVAT) demonstrated objective benefit in trials:
Chen et al. and other RCTs showed significant improvements in amplitude, facility, NPC and PFV versus placebo or control (chunks 55-58).
Specific trial effect sizes reported in Chen et al. (chunks 55-56).
inv-09: Non-surgical treatments for IXT and esotropia
Interventions for intermittent exotropia (IXT) and esotropia where some RCTs or meta-analyses show benefit:
Meta-analysis and RCTs found PTO superior to observation for several control and stereopsis outcomes (chunk 64).
Feng et al. RCT reported significant improvements in control scores and near stereoacuity (chunk 67).
Liang et al. RCT demonstrated greater improvements with combined therapy (chunk 62).
inv-10: Post-operative VR therapy — Adjunct post-operative interventions
Adjunct post-operative interventions:
Single RCT reported higher orthophoria rates and lower regression with post-op VR training (chunk 63).
inv-11: Digital perceptual learning for post-stroke visual field defects
Digital/VR visual perceptual learning for post-stroke visual field defects:
Namgung et al. trials used ≥6 dB sensitivity change and reported median/mean area improvements in adherent participants after 12 weeks (chunks 72-73).
inv-12: Digital/VR visual perceptual learning for chronic post-stroke visual field defects
Evidence from recent RCTs shows possible clinically meaningful improvements in visual field sensitivity in adherent patients; consider coverage when ALL of the following are met:
Trials required chronic VFD and neuroimaging-confirmed lesions (chunks 72-73).
Namgung et al. used ≥6 dB sensitivity and reported degrees² area changes (chunks 72-73).
High adherence in trials was critical to observed benefit (chunks 72-73).
Trials emphasized adherence and objective outcome measures; lack of objective compliance measures was a noted limitation (chunks 72-73).
inv-13: Compensatory visual scanning and task-specific training for post-stroke visual impairment or neglect
Evidence supports use of scanning training and integrated saccadic eye movement exercises to improve function and ADLs in some trials; consider coverage when ALL of the following are met:
Cochrane review and RCTs evaluated these interventions for ADL and balance outcomes (chunks 77,79).
Trials like Batool and Van Wyk reported functional gains with 4-week or longer programs (chunks 74,79).
Several small trials reported inter-group improvements on these scales (chunks 74,79).
inv-14: Prism adaptation (PA) for unilateral neglect — meta-analysis findings
Meta-analysis found no significant short- or long-term benefit compared with sham or no treatment; routine coverage not supported based on current evidence.
Consistent findings across studies with low heterogeneity; routine use of PA for unilateral neglect is not supported (chunk 75).
inv-15: Vision Restoration Therapy (VRT), perceptual learning, and non-invasive stimulation — experimental/investigational considerations
Evidence is mixed, limited, and of variable quality; consider these interventions experimental/investigational unless stronger evidence for the specific indication is provided.
Hayes and Park reviews and several small trials report inconsistent benefits and methodological limitations (chunks 84-86,90-92).
Navarro systematic review found low/moderate certainty evidence and noted minor AEs (chunk 88).
Policy frames these interventions as experimental absent stronger confirmatory evidence (chunks 84,88,90).
inv-16: Orthoptic/VT for dyslexia, learning disabilities, and visual information processing evaluations — evidence limited/mixed
Evidence is limited and mixed; orthoptic/VT and colored filters have isolated trial support but lack robust, generalizable evidence for routine coverage in learning disabilities.
Hussaindeen and similar small studies report BV parameter gains but are not generalizable for LD treatment (chunk 80).
Hall et al. showed reading gains in a trial but other RCTs like Ritchie found no immediate effect (chunk 81).
Studies show associations but do not establish diagnostic or therapeutic utility (chunks 82-83).
inv-17: Evidence summary for VRT — trial characteristics and limitations
Coverage depends on evidence of effectiveness and peer guidance; studies report improvements in perimetric detection but have limitations.
Sabel & Gudlin RCT and Mueller case series report technical improvements but generalizability is limited (chunks 90-92).
Policy recommends caution and requirement for stronger evidence or protocolized monitoring (chunks 90,92).
inv-18: Professional society stance on vision therapy and learning disabilities
Society statements inform coverage for indications such as learning disabilities and pediatric amblyopia screening follow-up.
Handler & Fierson 2011 joint technical report (chunk 93).
AAO PPP summarizes appropriate first-line approaches and notes limited evidence for VT (chunks 94,98).
inv-19: Stroke rehabilitation — orthoptist and eye movement therapy
NICE guidance for stroke-related visual field loss
NICE 2023 guidance recommends orthoptist assessment and eye movement therapy for persisting hemianopia (chunk 109).
Orthoptic or office-based Vision Therapy (VT) and related orthoptic services are considered not medically necessary when requested for indications other than documented convergence insufficiency. The policy lists these other indications as unproven, including use of virtual perceptual therapies for diagnosing or treating learning or language disorders and remote/digital VT for amblyopia, because the clinical evidence does not support efficacy for those conditions.
Use of digital or binocular therapies (including remote, online, or home-based dichoptic treatments) without documentation that standard therapy was attempted (for example, prior part-time patching or pharmacologic penalization) or without a plan for objective adherence monitoring and scheduled follow-up is not supported. Systematic reviews and RCTs report mixed results and frequent adherence issues, and the policy requires documentation of prior standard care or objective device adherence when considering these modalities.
Binocular/dichoptic approaches should not be presumed to universally replace conventional patching. Meta-analyses and randomized trials have found no consistent superiority of binocular therapies over patching and, in some trials, patching produced greater visual acuity gains; effectiveness of binocular approaches has been closely linked to adherence and study duration.
For clinical indications such as convergence excess, divergence excess or insufficiency, and nystagmus, there are no well-designed clinical trials demonstrating benefit of vision therapy. The policy therefore does not support routine coverage for VT for these indications due to lack of high-quality evidence.
Prism adaptation for unilateral post-stroke neglect is not routinely supported. A meta-analysis of randomized trials found no significant short- or long-term benefit of prism adaptation compared with sham or no treatment, and therefore routine coverage for prism adaptation in unilateral neglect is not indicated by the current evidence.
Behavioral or perceptual vision therapies (including training glasses, prisms, colored lenses/filters, and related VT interventions) are not supported as treatments for dyslexia or other learning disabilities. Professional society statements (AAP/AAO/AAPOS/AACO) conclude there is inadequate evidence that such visual interventions remediate learning disorders, and systematic reviews find limited and low-quality data for perceptual therapy approaches.
For visual symptoms attributed to mild traumatic brain injury (mTBI), the VA/DoD guideline states there is insufficient evidence to recommend for or against any specific modality (e.g., prism, VT, or digital interventions). Coverage decisions should reflect the lack of modality-specific endorsement in the guideline.
Operational note: certain CPT/HCPCS procedure codes referenced in this policy (including 0687T, 0688T, 0704T, 0705T, 0706T, 92066, and 92499) are not listed on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program. Verify plan- and state-specific coverage before submitting claims.
Remote, online, and digital therapies for amblyopia and related vision rehabilitation strategies are categorized across the policy as either covered with criteria (for selected FDA-cleared digital therapeutics and when trial-based eligibility, prior standard therapy, device-specific dosing, and adherence monitoring are documented) or as not medically necessary/experimental for other indications. The policy distinguishes device-specific, protocolized use (with documentation requirements) from unsupported routine remote VT claims.
Claims that remote or digital therapies are inherently superior to conventional treatments are not supported by high-quality evidence. Systematic reviews, evolving evidence assessments, and RCTs show mixed results, short follow-up, and adherence-related limitations; therefore routine assertions of superiority for remote/digital therapy are not sufficient to establish coverage.
Several randomized trials and meta-analyses have shown no advantage of home binocular/dichoptic therapy over standard patching in certain populations. Where trials demonstrated no benefit compared with standard therapy, the policy does not support routine home binocular/dichoptic therapy as a universal substitute for conventional occlusion without further evidence or documentation of prior standard treatment and adherence monitoring.
Evidence supporting orthoptic or vision therapy for exotropia and esotropia is limited and of variable quality. Some trials and meta-analyses report improvements in specific outcomes (e.g., office control score for intermittent exotropia), but long-term durability and generalizability are unclear. For stroke or traumatic brain injury contexts, evidence is also limited and inconsistent, and coverage should rely on documented objective pre/post measures and trial-based protocols when considered.
Many interventions are treated as experimental/investigational in this policy unless supported by stronger evidence for the specific indication. This includes a range of Visual Restoration Therapy (VRT) and perceptual learning platforms (e.g., RevitalVision and similar programs) and non-invasive electrical stimulation (NES/tDCS) when used outside of clinical trials or structured protocols. Coverage may be limited absent protocolized outcome monitoring or trial enrollment.
Professional society guidance from the AAP, AAO, AAPOS, and AACO indicates insufficient evidence to support vision training or vision therapy as treatments for learning disabilities; these position statements inform coverage exclusions for behavioral/perceptual VT and related interventions when used to treat dyslexia or learning disorders.
Procedure, CPT/HCPCS and Related Codes
| 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 |
| 92499 | Unlisted ophthalmological service or procedure |
| affected codes | VRT/computer-based vision rehabilitation — document did not list specific CPT/HCPCS codes in this section |
Authorization, Documentation, and Billing Guidance
Coding and documentation note
Include applicable procedure and diagnosis codes and supporting documentation when submitting claims. Codes listed in this policy are for reference only and do not guarantee coverage; verify member plan, state Medicaid fee schedules, and contractual requirements before billing. Note: several codes referenced (0687T, 0688T, 0704T, 0705T, 0706T, 92066, 92499) are not on the North Carolina Medicaid Fee Schedule and may not be covered for NC Medicaid members.
- When requesting authorization or submitting claims, include procedure and diagnosis codes listed in the policy and any additional codes required by the payer.
- Verify state- and plan-specific coverage rules prior to authorization or claim submission.
Required clinical documentation and prior therapy trial
Document baseline clinical measures and prior therapy trials before initiating advanced or digital treatments. Required documentation should include best-corrected visual acuity (BCVA) of the amblyopic eye, prior treatment type and duration (including trial of 2 hours/day patching), adherence information, and objective baseline testing (e.g., Humphrey visual field for VFDs, stereoacuity where relevant). Failure to document a prior adequate trial of standard therapy (for example, at least 12 weeks of 2 hours daily patching with documented lack of improvement and any dose escalation attempts) may lead to denial or request for additional information.
- Document baseline BCVA in the amblyopic eye and fellow eye (best-corrected).
- Document prior standard therapy: type (patching, atropine), prescribed dose (e.g., 2 hours/day), duration (e.g., ≥12 weeks), and objective evidence of treatment failure or plateau.
- If escalating patching (e.g., from 2 to 6 hours), include documentation that 2-hour trial was complete and details of response.
Authorization for home binocular/digital therapies — documentation should include device-specific details
Prior authorization may be recommended or required for select vision therapies, home binocular/digital devices, and VR/perceptual-learning therapeutics. When PA is requested, include indication, baseline testing results, prior conservative therapy trials (refractive correction, occlusion/atropine), and the proposed treatment protocol (device name, prescribed regimen, frequency and duration). For FDA-cleared digital therapeutics, document the device name, indication, patient age, and prescribed regimen.
- Include device-specific details for home binocular/digital therapies (manufacturer, model, FDA status, prescribed hours/week).
- For digital/VR perceptual learning in post-stroke visual field defects, include neuroimaging confirmation of visual pathway lesion when applicable.
Prior authorization — not specified in this section (operational note)
There are no direct administrative prior-authorization rules specified within this section of the policy document; operational PA triggers depend on member plan, state regulations, and payer-specific processes. Providers should check plan-specific PA portals or contact the payer for operational PA requirements.
- This policy does not itself create or specify an administrative PA requirement — verify with member's benefit plan.
- If PA is required by the plan, follow the plan's documentation checklist and include clinical evidence per other callouts.
Denial triggers for unproven services
Services lacking high-quality evidence or considered unproven are at risk for denial. Examples include behavioral/perceptual vision therapy for learning disabilities, vision restoration therapy for stroke when not meeting evidence-based criteria, and other restitutive interventions with insufficient high-quality trials. If the condition is not among those with proven benefit (e.g., amblyopia — occlusion/atropine; convergence insufficiency — orthoptics/VT; prism adaptation for esotropia), expect potential noncoverage.
- Denial may be issued for therapeutic approaches deemed experimental, investigational, or not medically necessary due to insufficient evidence.
- Vision therapy for learning disabilities and certain restitutive perceptual learning approaches may be considered not medically necessary.
Insufficient evidence leading to potential denial
Insufficient or low-quality evidence for certain indications may prompt denial or require prior authorization with robust supporting documentation. Examples include vision therapy for stroke/TBI, divergence disorders, convergence excess, nystagmus, and some perceptual-learning interventions where trials are small, heterogeneous, or lacking.
- Requests for these indications should include rationale, prior conservative treatments tried, and available objective outcome measures; however, coverage is uncertain and may be denied.
- For post-stroke digital therapeutics, require neuroimaging confirmation and objective baseline/ follow-up visual field testing.
Pediatric screening follow-up documentation
Pediatric vision screening and follow-up must be documented. Children who fail screening should be referred for a comprehensive eye exam; newborn abnormal red reflex requires urgent consultation. Document age-appropriate screening results, referrals, and outcomes of any comprehensive eye examinations.
- Document screening method (vision chart, photoscreener, handheld autorefractor), date, and results.
- Include documentation of referral to ophthalmology/optometry and any subsequent diagnostic findings or treatments.
Evidence supports use of conventional occlusion or atropine as effective first-line therapies; document trial of standard therapy
Evidence supports conventional occlusion (patching) and pharmacologic penalization (atropine) as effective first-line therapies for amblyopia; document a trial of standard therapy prior to coverage consideration for experimental or adjunctive digital options. Conventional refractive correction is the initial step in care and must be documented.
- Document refractive correction prescription, dates, and response before escalating to patching or other interventions.
- If considering digital therapeutics as adjuncts, include documentation that conventional measures were tried and the objective outcomes.
Several RCTs compared binocular/dichoptic therapies to conventional patching; document comparative findings where relevant
Several randomized controlled trials and systematic reviews compared binocular/dichoptic therapies to conventional patching. When requesting coverage for binocular/dichoptic or home-based digital therapies, include comparative findings when available and document adherence, objective VA outcomes, and why conventional therapy is inadequate or unsuitable for the patient.
- Provide device-specific trial data (duration, hours completed) and masked-examiner VA assessments where possible.
- Highlight RCT results if supporting noninferiority or superiority versus patching; also note limitations of trials (adherence, short follow-up).
Step therapy preference for compensatory strategies — consider conservative/compensatory strategies prior to experimental options
Consider stepwise, conservative management before experimental or restitutive interventions. Compensatory strategies (e.g., scanning training, prisms) may be preferred for post-stroke visual field deficits when evidence for restitutive interventions is limited. Document trials of conservative/compensatory approaches and rationale for pursuing experimental/perceptual learning therapies.
- Document prior use of compensatory training, prisms, or standard rehabilitation approaches and objective outcome measures before authorizing restitutive digital therapies.
- If surgery is being considered for strabismus, document non-surgical interventions tried and outcomes per conservative-step expectations.
Background and Scope
Amblyopia is defined as decreased visual acuity in one or both eyes due to abnormal visual development in infancy or childhood. Primary, evidence-based treatments include refractive correction followed by occlusion therapy (patching) or pharmacologic penalization (atropine), which are listed in the policy as proven and medically necessary for treating amblyopia.
Key Terms and Definitions
Policy Revisions and Change Log
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