Visual Information Processing Evaluation and Orthoptic and Vision Therapy (for North Carolina Only)
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Defines UnitedHealthcare coverage policy for orthoptic (vision) therapy, occlusion and pharmacologic penalization for amblyopia, prism adaptation, and visual information processing evaluation for members in North Carolina. Applies to providers delivering these services in that state.
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 Clinical Evidence and References sections to reflect the most current information.
Archived previous policy version CSNCT0072.03.
Coverage Criteria and Evidence Summary
Covered Treatments (proven and medically necessary)
Covered when treatment is for the listed, proven indications
Not Medically Necessary / Unproven
Not covered due to insufficient evidence of efficacy
Comparative efficacy and practical considerations
Evidence-based coverage considerations and comparative findings
Supported by Cochrane review, network meta-analysis, and PEDIG trials
Based on PEDIG randomized trial
Multiple RCTs and systematic reviews; see CureSight pivotal trial and systematic reviews
Affects strength of coverage decisions
Evidence summaries relevant to coverage
Summarized clinical findings relevant to coverage decisions
See CureSight pivotal trial, Xiao et al., and Yeh et al.
See systematic reviews and trial reports.
See PAS RCT and retrospective reviews.
Vision Therapy for Convergence Insufficiency and Accommodative Dysfunction
Covered when ALL of the following are met (examples based on available RCT evidence):
Overall
- Objective improvement endpoints: Demonstrated improvement in accommodative amplitude (diopters), accommodative facility (cpm), near point of convergence (cm), positive fusional vergence (Δ), or validated symptom scores (e.g., CISS)clinically meaningful change per trial
Chen et al., Sangoi et al., Scheiman et al.
OBVAT demonstrated consistent motor gains in RCTs
Non-surgical management of Intermittent Exotropia and Esotropia
Covered with criteria or considered when ALL of the following are met (intermittent exotropia/esotropia and post-surgical rehabilitation):
Cochrane and RCT evidence support patching and PTO versus observation for some improvement in control and alignment
Device-based Rehabilitation (VR, Digital Therapeutics)
Covered when ALL of the following are met (device-based digital therapeutics and VR interventions):
RCTs report clinically meaningful within-group and between-group improvements but with limitations of short follow-up and adherence-focused analyses
Evidence summary and coverage-relevant groupings
Summary of findings by intervention type and the conditions studied
Namgung et al. trials and related RCTs
Cavanaugh et al., Sabel & Gudlin, Jung et al.
Pollock and other systematic reviews
Qiu et al. 2021 meta-analysis
Navarro et al., Alber et al.
Hayes evolving evidence review, Park et al.
Joint AAP/AAO/AAPOS/AACO statements and evidence reviews
VRT efficacy evidence
Evidence from randomized trials and case series:
Sabel & Gudlin RCT, Jung et al. pilot RCT, Mueller case series
Guideline recommendations
Professional guideline statements:
Handler & Fierson, 2011 joint statement
AAO preferred practice pattern and related guidance
Stroke rehabilitation
Rehabilitation guidance:
NICE 2023 stroke rehabilitation guidance
Coverage considerations and clinical criteria
Guideline-supported care pathways and device-label indications referenced in this section:
USPSTF and AAO guidance
AOA, AAO, NICE, VA/DoD references
FDA device summaries
VA/DoD, NICE, AAO
This policy distinguishes between proven, medically necessary uses of orthoptic/vision therapy and other uses that lack sufficient evidence. Proven indications cited in the policy include: occlusion therapy or pharmacologic penalization for amblyopia, orthoptic/vision therapy for convergence insufficiency, and prism adaptation therapy for esotropia. Orthoptic or vision therapy for all other indications not listed above is considered unproven and not medically necessary unless specific supporting evidence is provided.
The available clinical evidence does not establish clear superiority of remote, online, or digital vision therapy over conventional treatments for amblyopia. Systematic reviews and evolving evidence assessments identify limitations including single-arm designs, short follow-up relative to a chronic condition, heterogeneous devices and protocols, and high dropout rates. As a result, claims that remote or digital therapies are superior to standard treatments (e.g., patching or atropine) are not supported by high-quality, consistent RCT evidence.
Some sections of the evidence summary and systematic reviews report findings for digital/remote therapies and for prism adaptation testing (PAT) without stating explicit categorical exclusions for those approaches. The document therefore presents the evidence and limitations for these interventions but does not list blanket procedural exclusions for all device-based or remote programs or for PAT in every chunk of the source text.
For certain indications — specifically convergence excess, divergence excess or insufficiency, and nystagmus — no well-designed clinical trials were identified. The lack of rigorous trial data for these conditions means there is insufficient evidence to support routine use of vision therapy for these diagnoses, and such requests may be denied absent high-quality supporting data.
A meta-analysis of randomized trials examining prism adaptation for unilateral post-stroke neglect found no consistent short- or long-term benefit compared with sham or no treatment. Consequently, routine use of prism adaptation to treat unilateral post-stroke neglect is not supported by the current evidence base.
Professional joint statements from pediatric and ophthalmology organizations note that behavioral/perceptual vision therapy, training glasses, prisms, and colored lenses/filters do not have sufficient evidence to treat learning disabilities. These modalities are not endorsed as effective treatments for dyslexia or related learning disorders and should not be presented as such in diagnostic or therapeutic plans.
FDA clearance or approval of a device or software is informational only and is not sufficient by itself to establish payer coverage. Coverage decisions should be based on the clinical evidence demonstrating effectiveness for the requested indication and alignment with policy criteria, not solely on regulatory status.
Operationally, certain CPT codes referenced in this policy (including 0687T, 0688T, 0704T, 0705T, 0706T, 92066, and 92499) are noted as not listed on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program. Providers billing in North Carolina should verify coverage and prior authorization requirements before providing services billed with these codes.
Virtual perception therapy and vision restoration approaches encompass device- or software-delivered visual perceptual learning (VPL) and computer-based repetitive stimulation protocols intended to improve detection sensitivity, visual field area, or functional visual tasks. Trials cited in the evidence base evaluated structured, protocolized programs with objective pre- and post-intervention measures (for example, Humphrey visual fields) and reported within-group improvements in some studies, but trial limitations affect generalizability and strength of conclusions.
Claims that remote or digital vision therapy is clearly superior to conventional treatments are not supported by the highest-quality evidence. Systematic reviews and randomized trials show mixed results: some small trials report benefit while pooled analyses and larger trials often show parity or favor conventional approaches, and heterogeneity and adherence issues limit definitive conclusions.
Systematic reviews and randomized trials comparing binocular/dichoptic therapy to patching have produced mixed results. Meta-analyses of RCTs did not demonstrate consistent superiority of binocular approaches over patching for visual acuity or stereopsis, while some individual trials reported comparable or modest benefits depending on adherence, age group, and study design. Overall, evidence does not uniformly support replacing patching with binocular therapy as the sole first-line treatment.
Evidence supporting orthoptic or vision therapy for exotropia is limited and inconclusive. A small RCT demonstrated improved control scores with office-based vergence therapies at short-term follow-up, but long-term benefit and consistent impact on the angle of deviation are not established. Routine vision therapy solely to change the deviation angle without objective documented deficits and measurable goals is not supported by robust evidence.
Meta-analytic evidence for prism adaptation in unilateral neglect after stroke does not demonstrate benefit over sham or no treatment; the pooled results were consistent across studies and did not support routine prism adaptation for this indication.
Vision therapy and related interventions lack adequate scientific support for treating dyslexia and learning disabilities. Major pediatric and ophthalmology organizations advise that such therapies are not effective for learning disorders and recommend that clinicians address bona fide visual defects by standard treatments while counseling families about the lack of evidence for VT as a learning-disability treatment.
The VA/DoD clinical practice guideline for post-acute mild traumatic brain injury states there is insufficient evidence to recommend for or against any particular modality for treating visual symptoms such as diplopia, accommodation or convergence deficits, visual tracking deficits, or photophobia. This reflects uncertainty about the effectiveness of specific vision therapy modalities in the post-TBI population.
Procedure and Device 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 |
| No codes listed |
| DEN210005 | FDA de novo classification for Luminopia One (device identifier from FDA) |
| K221375 | FDA decision number for CureSight 510(k) clearance referenced |
| K012530 | 510(k) for RevitalVision/NeuroVision AA-1 system |
| 0687T | CPT code flagged in policy history as not on NC Medicaid fee schedule |
| 0688T | CPT code flagged in policy history as not on NC Medicaid fee schedule |
| 0704T | CPT code flagged in policy history as not on NC Medicaid fee schedule |
| 0705T | CPT code flagged in policy history as not on NC Medicaid fee schedule |
| 0706T | CPT code flagged in policy history as not on NC Medicaid fee schedule |
| 92066 | CPT code flagged in policy history as not on NC Medicaid fee schedule |
| 92499 | CPT code flagged in policy history as not on NC Medicaid fee schedule |
Provider Responsibilities, Prior Authorization, and Documentation
Reference codes and prior authorization may apply
Reference codes listed in the policy are provided for informational purposes only and do not guarantee coverage or reimbursement. Prior authorization may be required for services described by certain CPT/HCPCS codes—verify plan-specific requirements before delivering or billing for services.
Evidence and adherence documentation for digital/binocular devices
For digital/binocular devices and software-based therapies (including home HMDs, eye-tracking systems, and prescription digital therapeutics), document objective evidence of treatment adherence and device usage and submit device labeling/indication information. Evidence should include pre- and post-treatment objective visual measures and device-derived adherence logs.
- Provide device name, manufacturer, FDA clearance/denovo or 510(k) reference and intended indication (e.g., CureSight, Luminopia One).
- Include device-supplied adherence data (hours used, percent of prescribed sessions completed) and any technical/telemetry summary reports.
- Correlate adherence with clinical outcomes in submitted documentation.
Device-based therapy prior authorization
Device-based therapies and advanced VT modalities frequently require prior authorization. For devices intended for amblyopia, visual field restoration, or VR-based perceptual learning, obtain prior authorization and supply the full therapy protocol and objective baseline and follow-up measures.
- Submit full treatment protocol (duration, frequency, total prescribed hours, supervised vs. unsupervised components).
- Include baseline and scheduled follow-up objective measures (e.g., BCVA in logMAR/ETDRS, Humphrey visual field indices, stereoacuity).
Prior authorization: therapy protocol and objective measures
Prior authorization submissions for therapy requests should include a clear protocol and objective measures to justify medical necessity and enable utilization review. Document baseline deficits, measurable therapy goals, specified assessment intervals, and pre-specified objective outcome thresholds.
- Specify baseline clinical measures: BCVA (ETDRS or Snellen with logMAR conversion), stereoacuity, prism and alternate cover test (PACT) angles, near point of convergence (NPC), accommodative amplitude and facility, and Humphrey visual fields as applicable.
- Provide planned assessment intervals (for example, baseline, 6–12 weeks, 12 weeks, and at therapy completion) and stop/go decision rules tied to objective improvement.
- If using a digital therapeutic, include masked-examiner VA assessments and device adherence reports.
Prior authorization recommended for VRT
Visual restoration therapy (VRT) should be considered high-utilization risk for prior authorization review due to variable evidence and adherence-dependent outcomes. Prior authorization is recommended to ensure appropriate patient selection, baseline testing, and monitoring plans are in place.
- Include Humphrey visual field (HVF) baseline and follow-up testing (same strategy: 24-2 or appropriate program).
- Provide objective improvement criteria (e.g., ≥6 dB sensitivity gain in specified regions or pre-defined degrees² visual area change).
Verify coverage / prior authorization for specific CPT codes
Verify coverage and prior authorization requirements for specific CPT and unlisted codes before billing. Some codes may be considered experimental or not covered under certain state plans.
Denial triggers and evidence limitations
Services inconsistent with the policy's evidence base or lacking required documentation may be denied. Denial triggers include submission without objective baseline or follow-up measures, absence of documented trial of guideline-preferred conservative therapy where required, missing device labeling/indication, or lack of adherence data for digital therapies.
- Requests for VT for indications listed as unproven (e.g., convergence excess, divergence excess/insufficiency, nystagmus, visual information processing for learning disabilities) risk denial.
- Absence of controlled-study evidence, small uncontrolled series, or reliance solely on FDA clearance without clinical evidence may prompt denial.
- Lack of NC Medicaid fee-schedule listing for a CPT may lead to noncoverage for NC Medicaid members.
Adherence and evidence limitations to anticipate
Be aware of specific evidence gaps that commonly lead to questioning medical necessity: lack of well-designed trials for convergence excess, divergence excess/insufficiency, or nystagmus; small uncontrolled studies; and outcomes driven primarily by adherence without sham-controlled comparisons.
- For convergence excess and nystagmus: submit any available trial data; absence of well-designed trials may result in noncoverage.
- For divergence excess/insufficiency: note that evidence is insufficient—provide robust documentation if requesting therapy.
- If cited studies lack control groups or have small sample sizes, include rationale and any supplemental objective outcome data to support effectiveness.
Required clinical indication and outcome documentation; device labeling; check benefit plan
Clinical documentation for coverage review should include: a clear clinical indication and history, prior conservative therapies attempted and responses, objective baseline and follow-up measures, device and manufacturer labeling/indication, and adherence data when applicable. Also confirm benefit plan-specific governing documents for exceptions or mandates.
- Document clinical indication and rationale for therapy (diagnosis, severity, prior treatments, reason for escalation).
- List prior conventional therapies and durations (e.g., refractive correction, patching, atropine) and treatment response.
- Include baseline and follow-up measures: BCVA (logMAR/ETDRS), stereoacuity, PACT angles, NPC, accommodative amplitude/facility, HVF indices where relevant, with dates and masked examiner notation when possible.
- Attach device labeling/indications and FDA clearance details if applicable.
- Check and cite the member's governing benefit plan documents and any state/federal coverage mandates.
Therapy escalation sequence and step-therapy expectations
Follow a stepwise therapy escalation approach consistent with specialty guidance: start with conservative, guideline-preferred therapies for amblyopia and strabismus before advanced or experimental modalities. Document trials and objective lack of improvement to support escalation.
- Amblyopia: expect trial of full-time refractive correction, then patching or pharmacologic penalization (e.g., atropine) before considering advanced VT or digital therapeutics.
- Intermittent exotropia and other strabismus: consider observation, patching, or prism/orthoptic approaches per evidence before PTO/advanced VT; document response to conservative measures.
- For convergence insufficiency: office-based vergence/accommodative therapy (OBVAT) has evidence—document conservative attempts and objective improvements (amplitude, facility, NPC, PFV).
Background and Rationale
Background: Amblyopia is reduced visual acuity resulting from abnormal visual development in infancy and childhood; standard, evidence-based treatments include refractive correction, occlusion (patching), and pharmacologic penalization (atropine). Orthoptic or vision therapy refers to supervised office-based exercises with home reinforcement designed to improve binocular function, accommodation, convergence, and oculomotor control. Professional guidance supports established primary treatments for amblyopia while recognizing that some targeted therapies (for example, orthoptic therapy for convergence insufficiency) have RCT support, whereas many other indications lack high-quality evidence.
Key Definitions
Policy Revision History
Added notation that 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.
Clinical Evidence and References sections updated to reflect the most current information (recent randomized trials and systematic reviews through 2024).
Previous policy version CSNCT0072.03 archived.
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