The submitted records have been reviewed. The member is an adult male with a birth date of 01/18/1994. He has a diagnosis of vision loss secondary to concussion. His treating provider, Jeffrey Becker, O.D., recommended occupational therapy/vision therapy from 10/28/2015 forward.
The carrier has denied coverage of occupational therapy/vision therapy from 10/28/2015 forward as experimental or investigational and not medically necessary. There is a letter from the carrier to the member dated 04/04/2016 which states in part:
“You did not meet the criteria coverage of Vision Therapy/Occupational Therapy…
The Geisinger Health Plan clinical Benefit Policy MP 277-Vision Therapy/Orthoptics states the requested Vision Therapy/Occupational Therapy …show more content…
He also demonstrated compensatory head tilt during evaluation and tilts his head to read and view objects at home, per his mother’s report. Impairments in these skills can cause difficulty with engagement in ADL’s/IADL’s including reading, writing, walking on uneven surfaces, and exercising. Skilled OT to address visual skills related to ADL’s and IADL’s is strongly recommended. By improving Sheldon’s performance with ADL’s/IADL’s, his quality of life can also be improved.”
Final External Review Decision:
The carrier’s decision to deny coverage for the requested occupational therapy/vision therapy from 10/28/2015 forward as experimental and investigational was appropriate.
The requested occupational therapy/vision therapy from 10/28/2015 forward is not medically necessary for the treatment of this member’s condition.
The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the member than any available standard health care service or …show more content…
The medical literature does not provide support, in the form of well-designed, randomized, controlled trials, for vision therapy (see the references below, which are reviews of the medical literature pertaining to this type of treatment). Further research is needed to establish the clinical value of this therapy.
Therefore, the carrier’s decision to deny coverage for the requested occupational therapy/vision therapy from 10/28/2015 forward as experimental/investigational was appropriate.
The requested occupational therapy/vision therapy from 10/28/2015 forward is not medically necessary for the treatment of this member’s condition.
The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the member than any available standard health care service or
The carrier has denied coverage of occupational therapy/vision therapy from 10/28/2015 forward as experimental or investigational and not medically necessary. There is a letter from the carrier to the member dated 04/04/2016 which states in part:
“You did not meet the criteria coverage of Vision Therapy/Occupational Therapy…
The Geisinger Health Plan clinical Benefit Policy MP 277-Vision Therapy/Orthoptics states the requested Vision Therapy/Occupational Therapy …show more content…
He also demonstrated compensatory head tilt during evaluation and tilts his head to read and view objects at home, per his mother’s report. Impairments in these skills can cause difficulty with engagement in ADL’s/IADL’s including reading, writing, walking on uneven surfaces, and exercising. Skilled OT to address visual skills related to ADL’s and IADL’s is strongly recommended. By improving Sheldon’s performance with ADL’s/IADL’s, his quality of life can also be improved.”
Final External Review Decision:
The carrier’s decision to deny coverage for the requested occupational therapy/vision therapy from 10/28/2015 forward as experimental and investigational was appropriate.
The requested occupational therapy/vision therapy from 10/28/2015 forward is not medically necessary for the treatment of this member’s condition.
The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the member than any available standard health care service or …show more content…
The medical literature does not provide support, in the form of well-designed, randomized, controlled trials, for vision therapy (see the references below, which are reviews of the medical literature pertaining to this type of treatment). Further research is needed to establish the clinical value of this therapy.
Therefore, the carrier’s decision to deny coverage for the requested occupational therapy/vision therapy from 10/28/2015 forward as experimental/investigational was appropriate.
The requested occupational therapy/vision therapy from 10/28/2015 forward is not medically necessary for the treatment of this member’s condition.
The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the member than any available standard health care service or