Medical policy: Vision Therapy

Policy number: MP 4.007

Effective date: 4/1/2026

Policy

Vision therapy may be considered medically necessary for symptomatic convergence insufficiency. Some examples (not all-inclusive) of conditions that can cause convergence insufficiency are the following conditions:

• Amblyopia
• Strabismus
• Accommodative dysfunction
• General binocular dysfunction
• Mild traumatic brain injury (mTBI)
• Concussion
• Stroke

More than 24 sessions of vision therapy are considered investigational per symptomatic occurrence (see policy guidelines).

Vision therapy is considered investigational for all other indications. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure.

Orthoptic eye exercises are considered investigational for the treatment of learning disabilities in the absence of symptomatic convergence insufficiency.

A home computer orthoptic program consisting of eye exercises performed when following computer instructions that is tailored to the individual’s personal binocular problem is considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure for these indications.

Policy guidelines

This policy addresses office-based orthoptic training. This policy does not address standard vision therapy with lenses, prisms, filters or occlusion (i.e., for treatment of amblyopia or acquired esotropia prior to surgical intervention).

Up to 12 sessions of office-based vision therapy, typically performed once per week, has been shown to improve symptomatic convergence insufficiency. If individuals remain symptomatic after 12 weeks of orthoptic training, yet there is documentation of improvement through examination notes, then another 12 sessions may be needed.

The American Association for Pediatric Ophthalmology and Strabismus states on their website:

At times, convergence insufficiency symptoms will resurface after illness, lack of sleep or increased near work demand. If treatment had been successful previously, an additional course of treatment may be successful at resolving recurrent symptoms.

A diagnosis of convergence insufficiency is based on asthenopic symptoms (sensations of visual and ocular discomfort at near point combined with difficulty sustaining convergence).

Convergence insufficiency and stereoacuity are documented by:

• Exodeviation at near vision at least 4 prism diopters greater than at far; AND
• Insufficient positive fusional vergence at near (positive fusional vergence [PFV] less than 15 prism diopters blur or break on PFV testing using a prism bar; AND
• Near point of convergence (NPC) break more than 6 cm; AND
• Appreciation by the patient of at least 500 seconds of arc on stereoacuity testing.

Cross-references

• MP 2.304 Medical Treatments of Autism Spectrum Disorders
• MP 6.058 Intraocular Lenses, Spectacle Correction, and Iris Prosthesis

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/background

Common forms of vision therapy are known as orthoptics and pleoptics. Orthoptics is a technique of eye exercises intended to improve eye movements and/or visual tracking. Pleoptics are eye exercises used to improve visual when there is no evidence of organic eye disease. A related but distinct training technique is behavioral or perceptual vision therapy, in which eye movement and eye coordination training techniques are used to improve learning efficiency by optimizing visual processing skills.

The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) states that optometrists define vision therapy as an attempt to develop or improve visual skills and abilities; improve visual comfort, ease and efficiency; and change visual processing or interpretation of visual information. The AAPOS states that there are main categories of vision therapy which are orthoptic vision therapy, behavioral/perceptual vision therapy, and vision therapy for prevention or correction of myopia (nearsightedness). Orthoptic vision therapy includes eye exercises to improve binocular function whereas behavioral/perceptual vision therapy includes eye exercises to improve visual processing and visual perception. Orthoptic eye exercises can be beneficial in the treatment of symptomatic convergence insufficiency.

Convergence insufficiency (CI) is a binocular vision disorder. The ability for the eyes to turn inward toward each other (e.g., when looking at near objects). It is most common in children and young adults when they begin to experience symptoms from prolonged periods of near work. Symptoms of this condition may include eyestrain, headaches, blurred vision, diplopia, sleepiness, difficulty concentrating, movement of print, and loss of comprehension after short periods of reading or performing close activities. Prism reading glasses, home therapy with pencil push-ups, and office-based vision therapy and orthoptics have been evaluated for the treatment of convergence insufficiency. Prism reading glasses tend to treat the symptom of double vision but does not actually correct the condition itself. The goal of vision therapy in the treatment of CI is to stimulate the communication between the brain and eyes, to enable clear and comfortable vision at all times.

In addition to its use in the treatment of accommodative and convergence dysfunction, vision therapy is being indicated for the treatment of attention deficit disorders, dyslexia, and reading disorders. The American Academy of Ophthalmology, in a joint statement on learning disabilities, dyslexia, and vision, concluded that:

Currently, there is no adequate scientific evidence to support the view that subtle eye or visual problems cause learning disabilities. Furthermore, the evidence does not support the concept that vision therapy or tinted lenses or filters are effective, directly or indirectly, in the treatment of learning disabilities. Thus, the claim that vision therapy improves visual efficiency cannot be substantiated. Diagnostic and treatment approaches that lack scientific evidence of efficacy are not endorsed or recommended.

Computer-based programs

RevitalVision received FDA clearance for its vision training software program which provides home-based vision training to people 9 years of age and older with amblyopia.

The CureSight system is a non-invasive eye tracking system designed for remote binocular vision treatment in pediatric patients (aged 4 to 9 years) suffering from amblyopia. The proprietary screen allows for treatment while the child watches their favorite streamed content in the comfort of their home.

Rationale

Summary of evidence

For individuals who have convergence insufficiency who receive office-based orthoptic training, the evidence includes a TEC Assessment, several randomized controlled trials (RCTs), and nonrandomized comparative studies. Relevant outcomes are symptoms and functional outcomes. The most direct evidence on office-based orthoptic training comes from a 2008 RCT that demonstrated improved visual symptoms of convergence insufficiency in a greater percentage of patients than a home-based vision exercise program consisting of pencil push-ups or home computer vision exercises. Subgroup analyses of this RCT demonstrated improvements in accommodative vision, parental perception of academic behavior, and specific convergence insufficiency symptoms. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have learning disabilities who receive office-based orthoptic training, the evidence includes a TEC Assessment as well as nonrandomized comparative studies. Relevant outcomes are symptoms and functional outcomes. A 1996 TEC Assessment did not find evidence that orthoptic training improves outcomes for individuals with learning disabilities. Since this publication, peer-reviewed studies have not directly demonstrated improvements in reading or learning outcomes with orthoptic training. At least 2 earlier studies that have addressed other types of vision therapies reported mixed improvements in reading. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have received computer-based therapy programs, the evidence includes a prospective study to evaluate the efficacy of perceptual vision therapy in enhancing best corrected visual acuity and contrast sensitivity function in amblyopic patients. The authors concluded the results demonstrate the efficacy of perceptual vision therapy in improving visual acuity. Long-term follow-up and further studies are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.

Definitions

Accommodation is the adjustment of the optics of the eye to keep an object in focus on the retina as its distance from the eye varies.

Amblyopia is reduced vision, typically in one eye, that results from the brain suppressing input from the affected eye due to unequal visual signals from each eye leading to poor development of visual acuity in the affected eye.

Binocular vision is the visual sensation that is produced when the images perceived by each eye are fused to appear as one.

Strabismus refers to an abnormal ocular condition in which the visual axes of the eyes are not directed at the same point.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Investigational; therefore, not covered:

Covered when medically necessary:

References

1. Handler SM, Fierson WM, American Academy of Ophthalmology Section on Ophthalmology and Council on Children with Disabilities, et al. Learning disabilities, dyslexia, and vision. Pediatrics. Mar 2011;127(3):e818-856. PMID 21357342
2. Rawstron JA, Burley CD, Elder MJ. A systematic review of the applicability and efficacy of eye exercises. J Pediatr Ophthalmol Strabismus. Mar-Apr 2005;42(2):82-88. PMID 15825744
3. Scheiman M, Gwiazda J, Li T. Non-surgical interventions for convergence insufficiency. Cochrane Database Syst Rev. Mar 16 2011(3):CD006768. PMID 21142896
4. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. Oct 2008;126(10):1336-1349. PMID 18852411
5. Scheiman M, Mitchell GL, Cotter S, et al. Long-term effectiveness of treatments for symptomatic convergence insufficiency in children. Optom Vis Sci. Sep 2009;86(9):1096-1103. PMID 19668097
6. Scheiman M, Cotter S, Kulp MT, et al. Treatment of accommodative dysfunction in children: results from a randomized clinical trial. Optom Vis Sci. Nov 2011;88(11):1343-1352. PMID 21870222
7. Borsting E, Mitchell GL, Kulp MT, et al. Improvement in academic behaviors after successful treatment of convergence insufficiency. Optom Vis Sci. Jan 2012;89(1):12-18. PMID 22080400
8. Barnhardt C, Cotter SA, Mitchell GL, et al. Symptoms in children with convergence insufficiency before and after treatment. Optom Vis Sci. Oct 2012;89(10):1512-1520. PMID 22922781
9. Scheiman M, Cotter S, Rouse M, et al. Randomized clinical trial of the effectiveness of base-in prism reading glasses versus placebo reading glasses for symptomatic convergence insufficiency in children. Br J Ophthalmol. Oct 2005;89(10):1318-1323. PMID 16170124
10. Scheiman M, Mitchell GL, Cotter S, et al. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol. Jan 2005;123(1):14-24. PMID 15642806
11. Shin HS, Park SC, Maples WC. Effectiveness of vision therapy for convergence dysfunctions and long-term stability after vision therapy. Ophthalmic Physiol Opt. Mar 2011;31(2):180-189. PMID 21309805
12. Dusek W, Pierscionek BK, McClelland JF. An evaluation of clinical treatment of convergence insufficiency for children with reading difficulties. BMC Ophthalmol. Aug 11 2011;11:21. PMID 21835034
13. Lee SH, Moon BY, Cho HG. Improvement of convergence movements by vision therapy decreases K-ARS scores of symptomatic ADHD children. J Phys Ther Sci. Feb 2014;26(2):223-227. PMID 24648636
14. Momeni-Moghadam H, Kundarti A, Azimi A, et al. The effectiveness of home-based pencil push-up therapy versus office-based therapy for the treatment of symptomatic convergence insufficiency in young adults. Middle East Afr J Ophthalmol. Jan-Mar 2015;22(1):97-102. PMID 25624682
15. Borsting E, Mitchell GL, Arnold LE, et al. Behavioral and emotional problems associated with convergence insufficiency in children: an open trial. J Atten Disord. Oct 2016;20(10):836-844. PMID 24271946
16. Ramsay MW, Davidson C, Ljungblad M, et al. Can convergence training improve reading in dyslexics? Strabismus. Dec 2014;22(4):147-151. PMID 25333204
17. Stein JF, Richardson AJ, Fowler MS. Monocular occlusion can improve binocular control and reading in dyslexics. Brain. Jan 2000;123(Pt 1):164-170. PMID 10611130
18. Christianson GN, Griffin JR, Taylor M. Failure of bi-level lens change reading scores of dyslexic individuals. Optometry. Oct 2001;72(10):627-633. PMID 11712629
19. Grisham JD, Powers MK. Visual skills of poor readers in high school. Optometry. Oct 2007;78(10):542-549. PMID 17904495
20. Palomo-Alvarez C, Puell MC. Accommodative function in school children with reading difficulties. Graefes Clin Exp Ophthalmol. Dec 2008;246(12):1769-1774. PMID 18751994
21. Ponsorby AL, Williamson E, Smith K, et al. Children with low literacy and poor stereoacuity: an evaluation of complex interventions in a community-based randomized trial. Ophthalmic Epidemiol. Sep-Oct 2009;16(5):311-321. PMID 19847111
22. Joint statement: learning disabilities, dyslexia, and vision reaffirmed 2014. American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists, et al. Updated July 2014.
23. Yalcin E, Balci O. Efficacy of perceptual vision therapy in enhancing visual acuity and contrast sensitivity function of amblyopic patients. Clin Ophthalmol. 2014;8:101-1247. PMID 24668026
24. Searle A, Rowe FJ. Vergence Neural Pathways: A Systematic Narrative Literature Review. Neuroophthalmology. 2016;40(5):209-218. PMID 28151870
25. Merezhinskaya N, Mallia AK, Park D, et al. Visual Deficits and Dysfunctions Associated with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Optom Vis Sci. 2019;96(8):542-555. PMID 31097071
26. Coats DK, Paysse EA. Causes of horizontal strabismus in children. In: UpToDate. Updated March 26, 2021. Literature review current through August 2022.
27. Álvarez TL, Scheiman M, Santos EM, Yaramorri C, et al. Convergence Insufficiency Neuromuscular Training in Adult Population Study Randomized Clinical Trial: Clinical Outcome Results. Optom Vis Sci. 2020;97(12):1061-1069. PMID 33207786
28. Chang MY, Morrison DG, Binanceam G, et al. Home- and Office-Based Vergence and Accommodative Therapies for Treatment of Convergence Insufficiency in Children and Young Adults: A Report by the American Academy of Ophthalmology. Ophthalmology. 2021;128(12):1756-1765. PMID 34140917
29. Scheiman M, Kulp MT, Cotter SA, Lawrenson JG, Wang L, Li T. Interventions for convergence insufficiency: a network meta-analysis. Cochrane Database Syst Rev. 2020 Dec 2;10(12):CD006768. PMID 33247009
30. Ghadban R, Martinez JM, Diehl NN, Mohney BG. The incidence and clinical characteristics of adult-onset convergence insufficiency. Ophthalmology. 2015 May;122(5):1050-1057. PMID 25626756
31. American Association for Pediatric Ophthalmology and Strabismus. Glossary Entry titled Vision Therapy. Updated April 2023.
32. American Association for Pediatric Ophthalmology and Strabismus. Glossary Entry titled Convergence Insufficiency. Updated March 2023.
33. Lazarus R. Convergence Insufficiency. Optometrists Network. April 22, 2020.
34. Fortenbaugh FC, Gustafson JA, Fonda JR, Fortier CB, Wilberg WP, McGlinchey RE. Blast mild traumatic brain injury is associated with increased myopia and chronic convergence insufficiency. Vision Res. 2021;186:1-12. PMID 32104004
35. Chen AM, Roberts TL, Cotter SA, et al. Effectiveness of vergence/accommodative therapy for accommodative dysfunction in children with convergence insufficiency. Ophthalmic Physiol Opt. Jan 2021;41(1):21-32. PMID 33119180