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Aetna Aetna
Clinical Policy Bulletin:
Low Vision Programs
Number: 0580


Policy

Aetna considers low vision programs medically necessary for members with a moderate or severe visual impairment, which is not correctable by conventional refractive means.  Ophthalmologic low vision evaluations and testing, instruction in the use of visual aids, interviews and counseling are medically necessary services typically included in a low vision therapy program.

For purposes of this policy, moderate to severe visual impairment is defined as follows:

  • Moderate visual impairment -- Best corrected visual acuity (BCVA) is less than 20/60 in the better eye (including 20/70 to 20/160)
  • Severe visual impairment -- BCVA is less than 20/160 (including 20/200 to 20/400); or visual field diameter is 20° or less (largest field diameter for Goldman isopter III4e, 1/100 white test object or equivalent) in the better eye.

Note: Most Aetna plans do not cover optical low vision devices (i.e., magnified visual aids) or non-optical low vision devices (e.g., large-print books, enlarged telephone dials, machines that talk) because vision aids are contractually excluded from coverage.  Please check benefit plan descriptions.



Background

Low vision is a visual impairment that is not correctable by standard eyeglasses, contact lenses, medicine, or surgery, and that interferes with a person’s ability to perform everyday activities.  Low vision should not be confused with blindness.  People with low vision still have useful vision that can often be improved with visual devices.  Whether the visual impairment is mild or severe, low vision generally means that the vision does not meet the patient’s need.

People of all ages may be affected with low vision.  Low vision can occur from birth defects, inherited diseases, injuries, diabetes, glaucoma, cataracts and aging.  The most common cause is macular degeneration, a disease of the retina causing damage to central vision.

Low vision intervention should begin as soon as the patient experiences difficulty performing ordinary every day tasks.  Intervention may come from the patient’s ophthalmologist or the patient may be referred to a low vision therapy program by his/her primary care physician.  Comprehensive management includes: (i) history of onset, and the effect of the visual impairment on daily life; (ii) examination for best corrected visual acuity, visual fields, contrast sensitivity, color perception, and glare sensitivity (if it pertains to the patient’s symptoms); (iii) evaluation of near vision and reading skills; (iv) selection and prescription of visual aids; (v) instruction in the correct use and application of the devices; and (vi) follow-up interviews or counseling to reinforce new patterns.

Orientation and mobility instruction aims to teach visually impaired individuals to ambulate and negotiate the environment safely and independently.  Instructors must prepare clients with visual impairment to manage various risks associated with everyday life, especially if they undertake independent travel in uncontrolled environments.  Through orientation and mobility training, visually impaired individuals are taught to enhance their mobility performance by using their remaining vision and other senses, such as hearing and touch.  The senses are supplemented by the use of devices such as long and support canes.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
HCPCS codes covered if selection criteria are met:
HCPCS codes not covered for indications listed in the CPB:
V2600 Hand held low vision aids and other nonspectacle mounted aids
V2610 Single lens spectacle mounted low vision aids
V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system
ICD-9 codes covered if selection criteria are met:
368.46 Homonymous bilateral field defects
368.47 Heteronymous bilateral field defects
369.01 Profound impairment, both eyes, better eye: total impairment; lesser eye: total impairment
369.03 Profound impairment, both eyes, better eye: near-total impairment; lesser eye: total impairment
369.04 Profound impairment, both eyes, better eye: near-total impairment; lesser eye: near-total impairment
369.06 Profound impairment, both eyes, better eye: profound impairment; lesser eye: total impairment
369.07 Profound impairment, both eyes, better eye: profound impairment; lesser eye: near-total impairment
369.08 Profound impairment, both eyes, better eye: profound impairment; lesser eye: profound impairment
369.12 Moderate or severe impairment, better eye, profound impairment lesser eye, better eye: severe impairment; lesser eye: total impairment
369.13 Moderate or severe impairment, better eye, profound impairment lesser eye, better eye: severe impairment; lesser eye: near-total impairment
369.14 Moderate or severe impairment, better eye, profound impairment lesser eye, better eye: severe impairment; lesser eye: profound impairment
369.16 Moderate or severe impairment, better eye, profound impairment lesser eye, better eye: moderate impairment; lesser eye: total impairment
369.17 Moderate or severe impairment, better eye, profound impairment lesser eye, better eye: moderate impairment; lesser eye: near-total impairment
369.18 Moderate or severe impairment, better eye, profound impairment lesser eye, better eye: moderate impairment; lesser eye: profound impairment
369.22 Moderate or severe impairment, both eyes, better eye: severe impairment; lesser eye: severe impairment
369.24 Moderate or severe impairment, both eyes, better eye: moderate impairment; lesser eye: severe impairment
369.25 Moderate or severe impairment, both eyes, better eye: moderate impairment; lesser eye: moderate impairment
Other ICD-9 codes related to the CPB:
V72.0 Examination of eyes and vision


The above policy is based on the following references:
  1. Mann RW. Low vision and blindness. J Rehabil Res Dev. 2000;37(2):xv-xvi.
  2. Hyvarinen L. Visual perception in 'low vision'. Perception. 1999;28(12):1533-1537.
  3. Heran F, Laloum L, Koskas P, et al. Low visual acuity, disorders of the visual field: How to adapt the imaging of optical pathways to clinical practice? J Neuroradiol. 1999;26(4):215-224.
  4. Ji YH, Park HJ, Oh SY. Clinical effect of low vision aids. Korean J Ophthalmol. 1999;13(1):52-56.
  5. Kupfer C. The National Eye Institute's low vision education program: Improving quality of life. Ophthalmology. 2000;107(2):229-230.
  6. Harper R, Doorduyn K, Reeves B, Slater L. Evaluating the outcomes of low vision rehabilitation. Ophthalmic Physiol Opt. 1999;19(1):3-11.
  7. Kupfer C. The Low Vision Education Program: Improving quality of life. Optom Vis Sci. 1999;76(11):729-730.
  8. Leat SJ, Legge GE, Bullimore MA. What is low vision? A re-evaluation of definitions. Optom Vis Sci. 1999;76(4):198-211.
  9. National Institutes of Health (NIH), National Eye Institute, National Eye Health Education Program. Low Vision: Help is Available [website].  Bethesda, MD: NIH; May 2000. Available at: http://www.nei.nih.gov/health/lowvision/index.htm. Accessed November 12, 2001.
  10. National Institutes of Health (NIH), National Eye Institute, National Eye Health Education Program. Are You at Risk for Age-Related Macular Degeneration? [website]. Bethesda, MD: NIH; August 2001. Available at: http://www.nei.nih.gov/health/maculardegen/armd_risk.htm. Accessed November 12, 2001.
  11. National Institutes of Health (NIH), National Eye Institute, National Eye Health Education Program. Facts About Age-Related Macular Degeneration [website]. Bethesda, MD: NIH, October 2001. Available at: http://www.nei.nih.gov/health/maculardegen/armd_facts.htm. Accessed November 12, 2001.
  12. American Academy of Ophthalmology (AAO). Resources for Individuals with Visual Impairment [website]. San Francisco, CA: AAO; September 2000. Available at: http://www.medem.com/MedLB/article_detaillb.cfm?article_ID=ZZZ952DGRJC&sub_cat=34. Accessed November 12, 2001.
  13. Faye EE. Low vision. In: General Ophthalmology. 15th ed. D Vaughan, T Asbury, P Riordan-Eva, eds. Stamford, CT: Appleton & Lange;1999:377-383.
  14. HGSAdministrators. Visual rehabilitation program. Medicare Part B Local Medical Review Policy. Contractor's Policy No. Y-12A. Camp Hill, PA: HGSA; January 15, 2001. Available at: http://www.xact.org/professionals/policy/y12a.html. Accessed November 12, 2001.
  15. Stelmack J. Quality of life of low-vision patients and outcomes of low-vision rehabilitation. Optom Vis Sci. 2001;78(5):335-342.
  16. Wilkinson ME. Low vision rehabilitation: A concise overview. Insight. 2003;28(4):111-117.
  17. Cheong AM, Lovie-Kitchin JE, Bowers AR, Brown B. Short-term in-office practice improves reading performance with stand magnifiers for people with AMD. Optom Vis Sci. 2005;82(2):114-127.
  18. Markowitz SN. Principles of modern low vision rehabilitation. Can J Ophthalmol. 2006;41(3):289-312.
  19. Lamoureux EL, Pallant JF, Pesudovs K, et al. The effectiveness of low-vision rehabilitation on participation in daily living and quality of life. Invest Ophthalmol Vis Sci. 2007;48(4):1476-1482.
  20. Agency for Healthcare Research and Quality (AHRQ). Vision rehabilitation: Care and benefit plan models. Literature Review. Rockville, MD: AHRQ; 2002.
  21. Agency for Healthcare Research and Quality (AHRQ). Vision rehabilitation for elderly individuals with low vision or blindness. Technology Assessment. Rockville, MD: AHRQ; October 6, 2004.
  22. Walter C, Althouse R, Humble H, et al. Vision rehabilitation: Recipients' perceived efficacy of rehabilitation. Ophthalmic Epidemiol. 2007;14(3):103-111.
  23. Virgili G, Rubin G. Orientation and mobility training for adults with low vision. Cochrane Database Syst Rev. 2010;(5):CD003925.
  24. Virgili G, Acosta R. Reading aids for adults with low vision. Cochrane Database Syst Rev. 2010;(5):CD003303.
  25. Stelmack JA, Tang XC, Reda DJ, et al; LOVIT Study Group. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol. 2008;126(5):608-617.
  26. Smallfield S, Clem K, Myers A. Occupational therapy interventions to improve the reading ability of older adults with low vision: A systematic review. Am J Occup Ther. 2013;67(3):288-295.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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