Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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bmchp.org | 888-566-0008 wellsense.org | 877-957-1300 Medical Policy

Vision Therapy Policy Number: OCA 3.40 Version Number: 15 Version Effective Date: 05/01/16

Product Applicability

All Plan+ Products

Well Sense Health Plan New Hampshire Medicaid NH Health Protection Program

Boston Medical Center HealthNet Plan MassHealth Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options

only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary

The Plan considers vision therapy as a standard treatment option for certain conditions medically necessary when medical criteria are met. Prior authorization is required. It will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested use. See the Plan’s policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment.

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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Description of Item or Service

Vision Therapy (VT): A treatment plan used to correct or improve specific dysfunctions of the vision system. Treatment plans encompass lenses, prisms, filters, occlusion (eye patching), and/or other appropriate materials or equipment and modalities or procedures, including eye exercises and behavioral modalities, that are used for eye movement and fixation training (as defined by the American Optometric Association). Vision therapy can also be called visual training or therapy or vision training, orthoptics, optometric vision therapy, orthoptic vision therapy, eye training, or eye exercises. Vision training, or orthoptics, typically addresses how well both eyes work together. Training is most often provided by an optometrist. See the member’s applicable benefit documents rather than this Plan policy for coverage of standard vision services which may include eye glasses, frames, and/or contact lenses; benefits documents are available at www.bmchp.org for BMC HealthNet Plan members, www.SeniorsGetMore.org for Senior Care Options members, and www.wellsense.org for Well Sense Health Plan members.

Medical Policy Statement

The Plan considers the use of vision therapy (up to 24 visits within 6 months of initiating treatment) medically necessary when the following criteria are met and documented in the member’s medical record, as specified below in item 1 and item 2:

1. The member has at least ONE (1) of the following four (4) clinical conditions, as specified below in items a through d:

a. Accommodative insufficiency; OR b. Amblyopia; OR c. Convergence insufficiency; OR d. Esotropia, acquired (prior to surgery); AND

2. The member meets the applicable clinical criteria listed below, as specified below in item a (for

the initial two [2] months of treatment) or item b (for continuing treatment after the initial two [2] months):

a. For the Initial Two (2) Months of Vision Therapy

ALL of the following criteria must be met for the initial two (2) months of vision therapy, as specified below in items (1) through (7):

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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(1) The initial evaluation includes quantifiable measurements to support the diagnosis and to establish the baseline against which follow-up evaluations can be measured; AND

(2) There is an expectation that vision therapy will produce measurable improvement in a

reasonable period of time; AND (3) The comprehensive treatment plan includes the projected period of treatment; AND (4) The number of visits per week and the total number of visits are determined based on

the nature and severity of the problem being treated and the needs of the individual receiving treatment; AND

(5) Member has a home program in addition to office visual therapy and documentation

of compliance is included in the records; AND (6) Follow-up evaluations are conducted at least monthly and include quantifiable

measurements and the percentage of improvement from the initial evaluation; AND (7) The provider documents all progress and any changes in the treatment plan; OR

b. For Continuing Treatment After the Initial Two (2) Months of Vision Therapy

ALL of the following criteria must be met for continuing treatment after the initial two (2) months of vision therapy, as specified below in items (1) through (5):

(1) Measurable improvement has been demonstrated within the first two months of treatment; AND

(2) Monthly evaluations demonstrate continued improvement over the prior month’s

evaluation; AND (3) The number of visits per week and the total number of visits are determined based on

the nature and severity of the problem being treated and the needs of the individual receiving treatment; AND

(4) Member has a home program in addition to office visual therapy and documentation

of compliance is included in the records; AND (5) The provider documents all progress and any changes in the treatment plan.

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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Limitations

1. The vision therapy is no longer considered medically necessary once further improvement

cannot be demonstrated. 2. Vision therapy for ANY of the following conditions is considered experimental and

investigational, as specified below in items a through e:

a. Language disorders including developmental delay; OR b. Learning disabilities including attention deficit hyperactivity disorder (ADHD), dyslexia, and

reading disabilities; OR

c. Strabismus with the exception of acquired esotropia; OR

d. Visual field defects following stroke and traumatic brain injury; OR

e. Any other diagnoses where there is not adequate authoritative evidence of vision therapy effectiveness, including but not limited to ANY of the following conditions, as specified below in items (1) through (37):

(1) Accommodative esotropia

(2) Anomalous (retinal) correspondence (3) Basic esophoria (4) Basic exophoria

(5) Brown’s tendon sheath syndrome (6) Chronic progressive ophthalmoplegia (7) Congenital nystagmus (8) Convergence excess (9) Cyclophoria (10) Cyclotropia (11) Deprivation amblyopia

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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(12) Dissociated vertical deviation (13) Divergence insufficiency (14) Duane’s syndrome (15) External ophthalmoplegia (16) Fourth cranial nerve palsies (17) Fusion with defective stereopsis (18) General binocular vision dysfunction (19) Hypertropia (20) Hypotropia (21) Latent nystagmus (22) Limited ductions (23) Microtropia (24) Monocular comitant esotropia (25) Monocular comitant exotropia (26) Ocular motor dysfunction - abnormal oculomotor studies (27) Ocular motor dysfunction - deficiencies of pursuit eye movements (28) Ocular motor dysfunction - deficiencies of saccadic eye movement (29) Psychological disturbances (30) Simultaneous vision without fusion (31) Sixth cranial nerve palsies (32) Strabismic amblyopia

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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(33) Suppression of binocular vision (34) Third cranial nerve palsies, total or partial (35) Total ophthalmoplegia (36) Visual deprivation nystagmus (37) Vertical heterophoria

See the Plan’s policy, Experimental and Investigational Treatment, policy number OCA 3.12, for the product-specific definitions of experimental or investigational treatment.

Definitions

Accommodation: The eye's ability to adjust its focus by the action of the ciliary muscle, which increases the lens focusing power. When this accommodation skill is working properly, the eye can focus and refocus quickly and effortlessly, which is similar to an automatic focus feature on a camera.

Accommodative Insufficiency: A lack of focusing ability at a near distance. Symptoms include eyestrain, blurred vision, occasional or constant when doing near work (such as reading or using a computer), occasional and unusual sensitivity to light, excess tearing, headaches, and general fatigue. Vision therapy is an effective treatment option.

Amblyopia (Lazy Eye): Poor vision in an eye that did not develop normal sight during early childhood. It is usually marked by blurred vision in one eye and favoring one eye over the other. Treatment options for functional amblyopia are eye patching, prescription lenses, prisms, and vision therapy.

Convergence Insufficiency (CI): The inability of the eyes to turn inward and/or sustain an inward turn. Symptoms include eyestrain with reading and using a computer, headaches, loss of comprehension, difficulty concentrating, blurred or double vision, and eye fatigue. Vision therapy is an effective treatment option.

Esophoria: Conditions in which, when both eyes are open, each eye points accurately at the target. However, upon covering one eye, the covered eye turns inwards. Also known as over-convergence.

Esotropia (ET): Conditions in which an eye is turned inward toward the nose. Esotropia is a type of strabismus. It is caused by a reduction in visual acuity, reduced visual function, high refractive error, traumatic brain injury, oculomotor nerve lesion, or eye muscle injury. Acquired esotropia is defined as crossed eyes that develop after a child reaches the age of six (6) months.

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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Exophoria: Conditions in which, when both eyes are open, each eye points accurately at the target. However, upon covering one eye, the covered eye turns outwards. Also known as under-convergence.

Exotropia (XT): Conditions in which an eye is turned outward toward the ear. Exotropia is a type of strabismus. It may also be called divergent strabismus, wandering eye, or wall eye(s). It is caused by a reduction in visual acuity, reduced visual function, high refractive error, traumatic brain injury, oculomotor nerve lesion, or eye muscle injury.

Hypertropia: A type of strabismus where one eye turns upward.

Hypotropia: A type of strabismus where one eye turns downward.

Learning Disability: A disorder that affects individual’s ability to either interpret what they see and hear or to link information from different parts of the brain. Learning disabilities can be divided into five broad categories: speech and language disorders, reading disorder, arithmetic disorder, writing disorder, and attention disorders. Orthoptics: A system of eye exercises to improve eye movement and visual tracking by strengthening eye muscles. Orthoptics is a limited form of optometric vision therapy and usually administered by an orthoptist who is a specialist that works under the supervision of an ophthalmologist. Pleoptics: A method of eye exercises created to stimulate and train an amblyopic eye. Strabismus (Squint): A condition in which the two eyes are directed to different points when looking at an object in space. Normally, in the absence of strabismus, the two eyes are directed to the same point when fixating on an object. This deviation of one eye may cause double vision and/or the suppression of vision in one eye. Strabismus is more common in children between the ages of 6 to 17 years, but it may also appear later in life.

Applicable Coding

The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Because the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service. Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines. Review Plan policy, Reimbursement Guidelines - Vision Services (policy number 4.38), available at www.bmchp.org for reimbursement guidelines applicable for covered vision services.

CPT Code Description: Code Covered When Medically Necessary

92065 Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

Clinical Background Information

Vision therapy is a nonsurgical clinical approach for treating functional visual deficiencies. Vision therapy includes a wide range of optometric treatment modalities such as lenses, prisms, filters, occluders, and specialized computer programs or instruments. Other modalities include eye exercise and behavioral modalities that are used for eye movement and fixation training with the overall goal to correct or improve specific dysfunctions of the vision system. Vision therapy is administered in an office setting under the guidance of an optometrist and requires a number of office visits with the length of the program varying from a few weeks to several months depending upon the severity of the visual condition being treated. Typically, patients are taught home exercises and activities to be done in conjunction with vision therapy to reinforce visual skills. There have been many studies that have evaluated the efficacy of vision therapy for a variety of visual disorders, however; in general, the data is weak and derived from poorly controlled studies. There is some evidence from the available studies that vision therapy may improve certain visual impairments such as amblyopia, acquired esotropia, convergence insufficiency, and accommodative deficiencies. Vision therapy is a controversial topic as there is no complete consensus between the opinions of specialists. Some ophthalmologists believe that eye exercises, lenses, prisms, and occlusion may benefit individuals with specific visual disorders; most do not believe that vision therapy is an effective treatment option for individuals with dyslexia and learning disabilities. Some optometrists advocate vision therapy for individuals with learning disabilities including dyslexia. A joint policy statement of the American Academy of Ophthalmologists, the American Academy of Pediatrics (AAP), and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) states that visual problems are rarely responsible for learning difficulties, and there is no scientific evidence supporting the use of vision therapy for learning disabilities.

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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At the time of the Plan’s most recent policy review, no clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) for vision therapy. Determine if applicable CMS criteria are in effect for this service in a national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request for a Senior Care Options member.

References

American Academy of Ophthalmology (AAO). Complementary Therapy Task Force. Complementary therapy assessment. Visual training for refractive errors. August 2013. Accessed at: http://www.aao.org/complimentary-therapy-assessment/visual-training-refractive-errors-cta--october-200 American Academy of Ophthalmology (AAO). AAO Pediatric Ophthalmology/Strabismus PPP Panel. Hoskins Center for Quality Eye Care. Preferred Practice Pattern.® Esotropia and Exotropia. 2012. Accessed at: http://www.aao.org/preferred-practice-pattern/esotropia-exotropia-ppp--september-2012 American Academy of Optometry and the American Optometric Association. Vision, Learning and Dyslexia. A Joint Organizational Policy Statement. 1997. Accessed at: http://c.ymcdn.com/sites/www.covd.org/resource/resmgr/position_papers/vision-therapy_-_jops_aao_&_.pdf American Academy of Optometry and the American Optometric Association. Vision Therapy. A Joint Organizational Policy Statement. 1999. Accessed at: http://c.ymcdn.com/sites/www.covd.org/resource/resmgr/position_papers/vision-learning-dyslexia_-_j.pdf American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Joint Statement—Learning Disabilities, Dyslexia, and Vision. Pediatrics. August 2009. Volume 124. Issue 2. Accessed at: http://pediatrics.aappublications.org/content/124/2/837 American Association for Pediatric Ophthalmology and Strabismus. Vision Therapy. Accessed at: http://www.aapos.org/terms/conditions/108 American Optometric Association. Optometric Clinical Practice Guideline. Care of the Patient with Accommodative and Vergence Dysfunction. 2010. Accessed at: http://www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines?sso=y

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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American Optometric Association. Optometric Clinical Practice Guideline. Care of the Patient with Amblyopia. 2004. Accessed at: http://www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines?sso=y American Optometric Association. Optometric Clinical Practice Guideline. Care of the Patient with Learning Related Vision Problems. Accessed at: http://www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines?sso=y American Optometric Association. Optometric Clinical Practice Guideline. Care of the Patient with Strabismus: Esotropia and Exotropia. 2010. Accessed at: http://www.aoa.org/documents/CPG-12.pdf Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Hayes Health Technology Brief. Vision Therapy for Convergence Insufficiency and Accommodative Dysfunction in Children. Winifred Hayes, Inc. December 17, 2013. Review November 13, 2015. Hayes Medical Technology Directory. Vision Therapy for Accommodative and Vergence Dysfunction. Winifred Hayes, Inc. November 29, 2011. Review May 5, 2015. Hayes Medical Technology Directory. Vision Therapy for Dyslexia and Other Reading and Learning Disabilities. Winifred Hayes, Inc. July 17, 2012. Review June 12, 2015. Hayes Search & Summary. Vision Therapy for Amblyopia in Children. Winifred Hayes, Inc. June 18, 2015. Hayes Search & Summary. Vision Therapy for Treatment of Visual Disturbances After Traumatic Brain Injury. Winifred Hayes, Inc. June 25, 2015. Institute for Clinical Systems Improvement (ICSI). Technology Assessment Report. Vision Therapy. 2003 Jan. Accessed at: www.i csi.org National Eye Institute (NEI). Amblyopia Treatment Study: Occlusion Versus Pharmacologic Therapy for Moderate Amblyopia. Clinical studies supported by the National Eye Institute. Accessed at: www.nei.nih.gov National Eye Institute (NEI). The Prism Adaptation Study (PAS). Clinical studies supported by the National Eye Institute. Accessed at: www.nei.nih.gov National Guideline Clearinghouse. Care of the patient with accommodative and vergence dysfunction. Accessed at: www.guideline.gov National Guideline Clearinghouse. Care of the patient with hyperopia. Accessed at: www.guideline.gov

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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National Guideline Clearinghouse. Care of the patient with strabismus: Esotropia and exotropia. Accessed at: www.guideline.gov Pediatric Eye Disease Investigator Group (PEDIG). Effectiveness of Home-Based Therapy for Symptomatic Convergence Insufficiency. Accessed at: http://pedig.jaeb.org/Studies.aspx?RecID=205 Pediatric Eye Disease Investigator Group (PEDIG). PEDIG Study Website. Accessed at: http://pedig.jaeb.org Scheiman M et al. A randomized Clinical Trial of Vision Therapy/Orthoptics versus Pencil Pushups for the Treatment of Convergence Insufficiency in Young Adults. Optometry and Vision Sciences. 2005 Jul;82(7):583-95.

Original Approval Date

Original Effective Date* and Version

Number Policy Owner Approved by

Regulatory Approval: N/A Internal Approval: 02/07/06

03/07/06 Version 1

Medical Policy Manager as Chair of Medical Policy, Criteria, and Technology Assessment Committee (MPCTAC) and member of Quality Improvement Committee (QIC)

Quality and Clinical Management Committee (Q&CMC)

*Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12

*Effective Date for the Well Sense Health Plan New Hampshire Medicaid Product(s): 01/01/13 *Effective Date for Senior Care Options Product(s): 01/01/16

Policy Revisions History

Review Date

Summary of Revisions

Revision Effective Date and Version

Number

Approved by

02/21/07 Added references. Version 2 02/21/07: Utilization Management Committee (UMC) 03/06/07: Q&CMC

03/11/08

No changes. Version 3 03/11/08: MPCTAC 03/25/08: UMC 04/15/08: QIC

02/24/09

No changes.

Version 4 02/24/09: MPCTAC 02/24/09: UMC 03/25/09: QIC

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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Policy Revisions History

02/01/10 Annual review, no changes. Version 5 02/22/10: MPCTAC 03/24/10: QIC

02/01/11

Updated references, no changes to criteria. Version 6 02/16/11: MPCTAC 03/23/11: QIC

02/01/12

Updated clinical criteria and changed the allowed number of visits from 32 visits per year to up to 24 visits within 6 months, updated References and Limitations sections.

Version 7 02/28/12: MPCTAC 03/23/12: QIC

08/01/12 Off cycle review for Well Sense Health Plan. Revised Summary statement, reformatted Medical Policy Statement, revised Applicable Coding introductory statement, updated code list (deleted diagnosis codes and reference to “without prior authorization”), revised Limitations.

Version 8 08/17/12: MPCTAC 09/06/12: QIC

11/01/12 Review for effective date 03/01/13. Updated references. Reformatted and added clinical criteria in Medical Policy Statement section. Reformatted Limitations section. Updated language in Applicable Coding section; deleted diagnosis codes and the note that specified diagnosis codes did not require prior authorization (since there are additional criteria that need to be met to obtain Plan prior authorization). Referenced the following policies: Experimental and Investigational Treatment, Medically Necessary, and Vision Services. Removed duplicate text in Clinical Background Information section.

03/01/13 Version 9

11/21/12: MPCTAC 12/20/12: QIC

08/14/13 and 08/15/13

Off cycle review for Well Sense Health Plan and merged policy format. Incorporate policy revisions dated 11/01/12 (as specified above) for the Well Sense Health Plan product; these policy revisions were approved by MPCTAC on 11/21/12 and QIC on 12/20/12 for applicable Plan products.

Version 10 08/14/13: MPCTAC (electronic vote) 08/15/13: QIC

11/01/13

Review for effective date 12/01/13. Updated references. Removed Well Sense Health Plan as an applicable product.

12/01/13 Version 11

11/20/13: MPCTAC 11/21/13: QIC

11/01/14 Review for effective date 03/01/15. Updated references. Clarified language in the Medical Policy Statement section. Updated Limitations section. Changed review calendar.

03/01/15 Version 12

11/19/14: MPCTAC 12/10/14: QIC

11/25/15 Review for effective date 01/01/16. Updated 01/01/16 11/18/15: MPCTAC

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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Policy Revisions History

template with list of applicable products and notes. Revised language in the Applicable Coding section.

Version 13 11/25/15: MPCTAC (electronic vote) 12/09/15: QIC

01/01/16 Review for effective date 03/01/16. Administrative changes made to the Description of Item or Service, Applicable Coding, and References sections.

03/01/16 Version 14

01/20/16: MPCTAC 02/10/16: QIC

03/01/16 Review for effective date 05/01/16. Revised the References, Clinical Background Information, and Reference to Applicable Laws and Regulations sections.

05/01/16 Version 15

03/16/16: MPCTAC 04/13/16: QIC

Last Review Date

03/01/16

Next Review Date

03/01/17

Authorizing Entity

QIC

Other Applicable Policies

Medical Policy - Contact Lens, policy number OCA 3.28 Medical Policy - Experimental and Investigational Treatment, policy number OCA 3.12 Medical Policy - Medically Necessary, policy number OCA 3.14

Reimbursement Policy - General Billing and Coding Guidelines, policy number 4.31 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number 4.108 Reimbursement Policy - Outpatient Hospital, policy number 4.17 Reimbursement Policy - Physician and Non Physician Practitioner Services, policy number 4.608 Reimbursement Policy - Vision Services, policy number 4.38

Reference to Applicable Laws and Regulations

78 FR 48164-69. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. August 7, 2013. Accessed at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

Vision Therapy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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The Commonwealth of Massachusetts. Massachusetts General Law. Chapter 118E. Division of Medical Assistance. Accessed at: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXVII/Chapter118E The Commonwealth of Massachusetts. MassHealth Provider Manual Series. Vision Care Manual. Accessed at: http://www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/provider-manual/vision-care-manual.html The Commonwealth of Massachusetts. MassHealth Provider Manual Series. Vision Care Manual. 402.433. Service Limitations. Contact Lens. Transmittal Letter VIS-37. June 01, 2008. Accessed at: http://www.google.com/url?url=http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-visioncare.rtf&rct=j&frm=1&q=&esrc=s&sa=U&ei=TeHsU86MMIGMyATz34G4BA&ved=0CBYQFjAA&usg=AFQjCNGguEBFjVKmpY-0GdhG0W9MmE9p8Q The Commonwealth of Massachusetts. MassHealth Vision Regulations. 130 CMR 402.000: Vision Care Services. Accessed at: http://www.mass.gov/courts/docs/lawlib/116-130cmr/130cmr402.pdf

Disclaimer Information: +

Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs.

Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members.

The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.