Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

Archived Coverage Decisions.

See Treatment Guidelines and Resources for additional information.

Occupational Health Best Practices and L&I header

Updated and effective: 07/01/2025

The department will cover office-based vision therapy (orthoptic training) for treatment of convergence insufficiency (CI) when traumatic brain injury (TBI) is an allowed condition on the claim and the CI is likely an outcome of TBI.

Conditions of coverage:

  • The initial evaluation must include measurable data to support the diagnosis of CI and to establish a baseline against which improvements can be measured. Measurable data must include at least the following:
    • Convergence Insufficiency Symptom Survey (CISS)score *
    • Near Point of Convergence (NPC)
    • Positive Fusional Vergence at near (PFV)

The department will allow up to 16 office-based vision therapy visits. Injured workers must have a home-based program of oculomotor exercises for CI (e.g., 15 min/day and 5 days per week) concurrently and be transitioned to a home-based program after the office-based treatment. The worker must keep a diary and report the progress from the home-based program, and the provider must document such progress.

  • Up to an additional 16 office-based vision therapy visits may be covered when the worker has not attained normal convergence, and if all the following criteria are met:
    • Individual has shown evidence of clinically significant improvement after the initial treatment visits as demonstrated by an improved (or normal) CISS score and at least an improved (or normal) NPC or an improved (or normal) PFV:
      • A decrease of ≥10 points on CISS score is considered improved (CISS <21 is considered normal);
      • A decrease of > 4 cm on NPC is considered improved (NPC <6 cm is considered normal);
      • An increase of > 10∆ on PFV is considered improved (normal PFV is greater than 15∆)
    • The improvements must be clearly documented before additional treatment is authorized. The worker must keep a diary and report the progress from the home-based program, and the provider must document such progress.

Non-covered indicators:  Vision therapy is not covered for the following:

  • Convergence insufficiency that occurred without traumatic brain injury or prior to the industrial injury
  • Unspecified brain disorder
  • The worker has attained normal convergence (i.e., a normal CISS score, a normal NPC and a normal PFV).

*CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY