COLLEGE OF OPTOMETRISTS IN VISION DEVELOPMENT

INTERNATIONAL OFFICE -- 243 N. Lindbergh Blvd. Ste 310 -- St. Louis, MO 63141-7851 -- (314)991-4007 1-888-COVD770 FAX(314)991-1167

A PATIENT'S GUIDE TO INSURANCE COVERAGE FOR VISION THERAPY

Introduction

Each year thousands of individuals benefit from the enhanced and improved visual abilities provided through vision therapy. This specialized area of vision care is sometimes also referred to as visual training, orthoptics or eye exercises. It can be effective in treating many types of vision problems relating to:

Although forms of vision therapy have been utilized for over 100 years in treating crossed-eyes and lazy eye, in the last 40 to 50 years the use of vision therapy has expanded to include treatment of most types of binocular vision and visual perception problems. The benefits of vision therapy have been demonstrated through improved vision obtained by thousands of patients and a substantial body of research.

Vision therapy is a recognized area of optometric care. While all optometrists receive some training in this area as part of their professional education, currently only about 30% include this area of care in their practice services. Optometrists, who do not offer this service, often refer their patients to another optometrist who specializes in vision therapy.

Insurance coverage for vision therapy

Vision therapy is used to treat diagnosed vision conditions. In some cases, vision therapy is the only available and effective treatment option for these conditions. Treatment may be covered under major medical insurance plans. However, some insurance companies and managed care plans may deny or place severe limits on coverage for vision therapy services as a cost saving measure.

Under all forms of medical insurance plans, you the patient, have a right to request a review of any service that is denied coverage, or for which coverage is severely limited, if you believe the plan has incorrectly evaluated the claim for coverage, acted arbitrarily, or discriminated unfairly against you.

There are several steps you can take to have a denial of coverage of vision therapy reconsidered. While the doctor who provided the services to you or your family member can possibly assist you in filing for reconsideration, the ultimate responsibility is yours.

The insurance plan under which you have medical coverage is a contract between the insurance company or managed care plan and you. Even if your employer pays for the coverage, you have certain rights under the plan regarding what services are to be provided and how they are to be paid.

Steps to consider in requesting a Review of Denial of Coverage for Vision Therapy

  1. First, review your medical plan's Explanation of Benefits booklet to see if there is any statement about the inclusion or exclusion of coverage for vision therapy or orthoptics. Some plans explicitly exclude coverage for these services.

    Some plans may exclude coverage for vision therapy to treat educational problems such as learning disabilities, dyslexia, etc. The treatment of learning problems and dyslexia are educational problems and are not within the purview of major medical insurance coverage. However, this should not preclude your receiving coverage for vision therapy for treatment of a diagnosed vision problem. Although vision problems can and do interfere with an individuals ability to learn, vision therapy is not used to directly treat educational problems. However, once a vision problem is corrected with vision therapy, an individual's educational abilities may improve significantly.

  2. Ask for a written statement on the exact reason that coverage was denied or limited. If an arbitrary statement is given that the company or plan has concluded that vision therapy is not considered medically necessary, or is not effective in treating the diagnosed problem, ask for documentation to support that claim.

    Many research studies and clinical reports have been published that support the effectiveness of vision therapy/orthoptics. Unfortunately, your insurance company or plan may not have reviewed this information.

  3. Some insurance plans may indicate that the services were reviewed by their "medical consultant," who has recommended the services not be covered. You may wish to inquire as to the qualifications of the consultant to make that determination.

    It is common medical practice for questions regarding the medical necessity or appropriateness of treatment to be reviewed by a "medical peer," another doctor with similar training and knowledge in the particular area of care. If the claim for vision therapy services was not reviewed by an optometrist who also provides these services, then true "peer review" did not occur.

  4. The College of Optometrists in Vision Development (COVD) is an international certification body for doctors who provide vision therapy services. Fellows of COVD (FCOVD) are Board Certified in Vision Development and Therapy. To obtain true peer review services for vision therapy, you can request your claim be reviewed by a Fellow of the College of Optometrists in Vision Development, or by the Peer Review Committee of the College.

    When claims are denied on the basis that the insurance company or their consultant believes there is lack of sufficient research to support the effectiveness of vision therapy, supplying documentation of available research may result in approval of coverage.

  5. Compilation of research and clinical studies are available from the following sources:

      6.  

      American Optometric Association

      243 North Lindbergh Blvd.

      St. Louis, MO 63141

      1-800-365-2219

       

      College of Optometrists in Vision Development

      243 North Lindbergh Blvd.

      #310 St. Louis, MO 63141

      1-888-268-3770

  6. If after going through the above process, coverage of your claim for vision therapy is still denied, you may want to consider the following actions:

      7.  

      • If your medical insurance coverage is provided by your employer, bring the problem to the attention of your company's Employment Benefits Manager and ask for his or her assistance.
      • If you purchase insurance coverage yourself, contact your insurance agent to ask for help in getting your claim paid.
      • If you are unable to obtain satisfactory resolution of your claim, consider filing a complaint with the office of your state commissioner of insurance.

       

  7. It is important to remember that the unwillingness of your insurance company to pay for these services does not reduce the need for obtaining treatment. Talk with your doctor about payment options that may be available to assist you or your family in obtaining needed care.

This information is provided as a general guideline to assist you in inquiring about coverage for vision therapy services under your insurance plan. For additional information on vision therapy, please visit our website at www.covd.org or call the COVD office at 1-888-268-3770.

Permission to reprint the contents above granted to P.A.V.E ® - 02/05/02 by the College of Optometrists in Vision Development.

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