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.
See Treatment Guidelines and Resources for additional information.
The department will cover office based vision therapy for treatment of convergence insufficiency (CI) when traumatic brain injury is an allowed condition on the claim. All other cases of CI will require additional review.
CI can occur without traumatic brain injury. Individuals with long standing CI are likely to have amblyopia or reduced vision in one eye and also have a history of prism use or strabismus prior to the industrial injury.
The department will not authorize payment for vision therapy as a treatment for
- Unspecified brain disorder,
- Convergence excess,
- Divergence insufficiency and divergence excess,
- Accommodative insufficiency,
Number of sessions allowed: The department will allow 12 office based vision therapy treatments. For additional treatments to be authorized, objective evidence of improvement (e.g. near point convergence (NPC) and positive fusional vergence at near) should be documented.
CPT ® Code 92065 - Orthoptic and/or pleoptic training