Low Vision Programs

Number: 0580

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses low vision programs.

  1. Medical Necessity

    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.

  2. Policy Limitations and Exclusions

    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.

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

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-10 codes covered if selection criteria are met:
H53.461 - H43.469 Homonymous bilateral field defects
H53.47 Heteronymous bilateral field defects
H54.0X33 - H54.0X55 Blindness, both eyes
H54.10 - H54.1225 Blindness, one eye, low vision other eye
H54.2X11 - H54.3 Low vision, both eyes
H54.40 - H54.42A5 Blindness, one eye
H54.50 - H54.52A2 Low vision, one eye

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:
  1. history of onset, and the effect of the visual impairment on daily life;
  2. examination for best corrected visual acuity, visual fields, contrast sensitivity, color perception, and glare sensitivity (if it pertains to the patient’s symptoms);
  3. evaluation of near vision and reading skills;
  4. selection and prescription of visual aids;
  5. instruction in the correct use and application of the devices; and
  6. 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.

References

The above policy is based on the following references:

  1. Agency for Healthcare Research and Quality (AHRQ). Vision rehabilitation: Care and benefit plan models. Literature Review. Rockville, MD: AHRQ; 2002.
  2. 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.
  3. 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.
  4. 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.
  5. Faye EE. Low vision. In: General Ophthalmology. 15th ed. D Vaughan, T Asbury, P Riordan-Eva, eds. Stamford, CT: Appleton & Lange;1999:377-383.
  6. Hamade N, Hodge WG, Rakibuz-Zaman M, Malvankar-Mehta MS. The effects of low-vision rehabilitation on reading speed and depression in age related macular degeneration: A meta-analysis. PLoS One. 2016;11(7):e0159254.
  7. Harper R, Doorduyn K, Reeves B, Slater L. Evaluating the outcomes of low vision rehabilitation. Ophthalmic Physiol Opt. 1999;19(1):3-11.
  8. 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.
  9. HGSAdministrators. Visual rehabilitation program. Medicare Part B Local Medical Review Policy. Contractor's Policy No. Y-12A. Camp Hill, PA: HGSA; January 15, 2001.
  10. Hyvarinen L. Visual perception in 'low vision'. Perception. 1999;28(12):1533-1537.
  11. Ji YH, Park HJ, Oh SY. Clinical effect of low vision aids. Korean J Ophthalmol. 1999;13(1):52-56.
  12. Kupfer C. The low vision education program: Improving quality of life. Optom Vis Sci. 1999;76(11):729-730.
  13. Kupfer C. The National Eye Institute's low vision education program: Improving quality of life. Ophthalmology. 2000;107(2):229-230.
  14. Lam N, Leat SJ, Leung A. Low-vision service provision by optometrists: A Canadian nationwide survey. Optom Vis Sci. 2015;92(3):365-374.
  15. 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.
  16. Leat SJ, Legge GE, Bullimore MA. What is low vision? A re-evaluation of definitions. Optom Vis Sci. 1999;76(4):198-211.
  17. Mann RW. Low vision and blindness. J Rehabil Res Dev. 2000;37(2):xv-xvi.
  18. Markowitz SN. Principles of modern low vision rehabilitation. Can J Ophthalmol. 2006;41(3):289-312.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. Stelmack J. Quality of life of low-vision patients and outcomes of low-vision rehabilitation. Optom Vis Sci. 2001;78(5):335-342.
  24. 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.
  25. Stelmack JA, Tang XC, Wei Y, et al. Outcomes of the Veterans Affairs Low Vision Intervention Trial II (LOVIT II): A randomized clinical trial. JAMA Ophthalmol. 2017;135(2):96-104.
  26. Tey CS, Man REK, Fenwick EK, et al. Effectiveness of the "living successfully with low vision" self-management program: Results from a randomized controlled trial in Singaporeans with low vision. Patient Educ Couns. 2019;102(6):1150-1156.
  27. Virgili G, Acosta R. Reading aids for adults with low vision. Cochrane Database Syst Rev. 2010;(5):CD003303.
  28. Virgili G, Rubin G. Orientation and mobility training for adults with low vision. Cochrane Database Syst Rev. 2010;(5):CD003925.
  29. Walter C, Althouse R, Humble H, et al. Vision rehabilitation: Recipients' perceived efficacy of rehabilitation. Ophthalmic Epidemiol. 2007;14(3):103-111.
  30. Wilkinson ME. Low vision rehabilitation: A concise overview. Insight. 2003;28(4):111-117.