Latest Review Date: April 2024

Category:  Vision

POLICY:

Visual perceptual training (VPT) is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Visual Perceptual Training (VPT) is an intervention that is used to treat learning disabilities.  The training focuses on perceptual dysfunctions, which that have been proposed as a contributing factor to speech and language developmental delay in preschool children. Visual perceptual disabilities is defined as “that process by which impressions observed through the medium of the eye are transmitted to the brain where relationship to past experiences takes place.” It is believed that there is a close relationship between visual perception and the learning process.  Visual perception dysfunction has been classified as a learning disability and language disorder.

Visual perception training programs integrate speech and language activities, a wide range of sensory modalities, and various visual-motor perceptual activities (e.g. motor rhythm activities, body image training). The activities of the program are grouped into five main headings: coordination of eye-motor movements, distinguishing foreground from background, visual memory, spatial position, and relationship to space.  In the development of this program, major emphasis was placed on relating all activities, whether motor, kinesthetic, visual or other, to reading, writing, and arithmetic. 

Visual perceptual training is not the same as vision therapy. Visual perceptual training is directed toward perceptual dysfunctions that are believed to affect language and learning abilities. Vision therapy is a set of exercises directed toward specific deficiencies in the movements and/or focusing of the eye (e.g., convergence insufficiency, disorders of accommodation, esophoria, strabismus, etc.). Visual perceptual training is generally provided by psychologists, psychotherapists, occupational therapists, or other behavioral health professionals. Vision therapy is provided by an optometrist or eye care professionals. 

KEY POINTS:

The most recent literature review was performed through April 17, 2024.

Summary of Evidence

Visual perceptual training is considered behavioral and educational training in nature. The available data supporting the use of visual perceptual therapy to treat learning or developmental disabilities is derived primarily from uncontrolled or poorly controlled studies with significant methodological flaws. There is a paucity of well-designed trials and/or scientific evidence that proves visual perceptual therapy is an effective treatment for learning disabilities and/or disorders. Well-designed randomized controlled studies are needed to validate the effectiveness of visual perceptual training. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Pediatrics et al

In 2009 (reaffirmed in 2014), the American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists issued a joint policy statement on pediatric learning disabilities, dyslexia, and vision. For vision therapy, the statement concluded:

“Currently, there is no adequate scientific evidence to support the view that subtle eye or visual problems cause learning disabilities. Furthermore, the evidence does not support the concept that vision therapy or tinted lenses or filters are effective, directly or indirectly, in the treatment of learning disabilities. Thus, the claim that vision therapy improves visual efficiency cannot be substantiated. Diagnostic and treatment approaches that lack scientific evidence of efficacy are not endorsed or recommended.”

In 2011, these same four associations also published a joint technical report on learning disabilities, dyslexia, and vision. This report concluded: “There is inadequate scientific evidence to support the view that subtle eye or visual problems cause or increase the severity of learning disabilities…. Scientific evidence does not support the claims that visual training, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision therapy, ‘training’ glasses, prisms, and colored lenses and filters are effective direct or indirect treatments for learning disabilities.”

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Visual perceptual training (VPT), learning disability, perceptual dysfunction

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan. 

CURRENT CODING:

CPT Codes:  

There are no specific CPT codes to report this service, the following codes might be used:

REFERENCES:

1. Alley GR. Perceptual-motor performances of … children after systematic visual-perceptual training. Am J Ment Defic. 1968; 73(2):247-250.
2. American Academy of Pediatrics. Learning disabilities, dyslexia, and vision: A subject review. Committee on Children with Disabilities, American Academy of Pediatrics (AAP) and American Academy of Ophthalmology (AAO), American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Pediatrics. 1998; 102(5):1217-1219.
3. Anderson SW.  Neuropsychologic rehabilitation for visuoperceptual impairments.  Neurology Clinics, August 2003; 21(3): 729-740.
4. Astle AT, Webb BS, McGraw PV.  Can perceptual learning be used to treat amblyopia beyond the critical period of visual development?  Opthalmic Physio Opt. 2011; 31(6):564-573.
5. Beitchman JH and Young AR.  Learning disorders with a special emphasis on reading disorders:  A review of the past 10 years.  Journal of the American Academy Adolescent Psychiatry, August 1997; 36(8): 1020-1032.
6. Brenton J, Müller S, Harbaugh AG. Visual-perceptual training with motor practice of the observed movement pattern improves anticipation in emerging expert cricket batsmen. J Sports Sci. 2019;37(18):2114-2121.
7. Cunningham SA and Reagan CL.  Handbook of visual perceptual training.  Charles C. Thomas Publisher 1972, Springfield, Illinois.
8. Fahle M.  Perceptual learning:  Specificity versus generalization.  Current Opinions Neurobiology, April 2005; 15(2): 154-160.
9. Galuschka K, Schulte-Korne G. The diagnosis and treatment of reading and/or spelling disorders in children and adolescents. Dtsch Arztebl Int. 2016; 113(16):279-286.
10. Grigoriera L, Bernadskaya M, et al.  Visual perceptual training of children with multiple disabilities in Russia.  In:  Proceedings of ICEVI’s Xth World Conference.  Stepping Forward Together:  Families and Professionals as Partners in Achieving an Education for All.  Sao Paulo, Brazil, August 3-8, 1997, www.icevi.org/.
11. Hallahan DP and Mercer CD.  Educational programming:  Dominance of psychological processing and visual perceptual training.  In:  Learning Disabilities:  Historical Perspectives.  Learning Disabilities Summit:  Building a Foundation for the Future White Papers, Nashville, TN.  National Research Center for Learning Disabilities, August 2001, www.nrcld.org/resources/1dsummit/hallahan.pdf.
12. Handler SM, Fierson WM, Section on Ophthalmology SM. Learning disabilities, dyslexia, and vision. Pediatrics. Mar 2011; 127(3): e818-56.
13. Hicks C.  Remediating specific reading disabilities:  A review of approaches.  Journal of Research in Reading 1986; 9(1): 39-55.
14. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
15. Joint statement: learning disabilities, dyslexia, and vision reaffirmed 2014. American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists, et al. https://www.aao.org/clinical-statement/joint-statement-learning-disabilities-dyslexia-vis.
16. Keogh BK, et al.  Vision training revisited.  Journal of Learning Disability, April 1985; 18(4): 228-236.
17. Kronenberger WG, et al.  Learning disorders.  Neurology Clinics, November 2003; 21(4): 941-952.
18. Marks HB. Evaluation of visual perceptual training for reading disabilities. R I Med J. 1970; 53(3):150-151 passim.
19. Martin JC. Effects of visual perceptual training on visual perceptual skills and reading achievement. Percept Mot Skills. 1973; 37(2):564.
20. Merck Manuals Online Medical Library.  Learning disabilities.  Merck and Co, August 2007, www.merck.com/mmpe/sec19/ch299/ch299d.html.
21. Miller SR, Sabatino DA, Miller TL. Influence of training in visual perceptual discrimination on drawings by children. Percept Mot Skills. 1977; 44(2):479-487.
22. National Institute of Neurological Disorders and Strokes (NINDS).  NINDS Dyslexia Information Page. www.ninds.nih.gov/disorders/dyslexia/hyslexia.htm.
23. National Institute of Neurological Disorders and Strokes (NINDS).  NINDS Learning Disabilities Information Page.  www.ninds.nih.gov/disorders/learningdisabilities/learningdisabilites.htm.
24. Olitsky SE, et al.  Reading disorders in children.  Pediatric Clinics of North America, February 2003; 50(1): 213-224.
25. Rosen CL. An experimental study of visual perceptual training and reading achievement in first grade. Percept Mot Skills. 1966; 22(3):979-986.
26. Schoeman OJ.  The therapeutic value of visual-perceptual training and its effect on scholastic achievement.  South African Medical Journal 1996; 86(8): 983.
27. Seitz AR, et al.  Seeing what is not there shows the costs of perceptual learning.  Procedure National Academy Science USA, June 2005; 102(25): 9080-9085.
28. Shaywitz SE.  Dyslexia.  NEJM, January 1998; 338(5): 307-312.
29. Tannock R.  Learning disorders.  Kaplan & Saddock’s Comprehensive Textbook of Psychiatry, Chapter 35.  Philadelphia:  Lippincot, Williams and Wilkins 2005.
30. Walsh JF, D'Angelo R. Effectiveness of the Frostig program for visual perceptual training with Head Start children. Percept Mot Skills. 1971; 32(3):944-946.

POLICY HISTORY:

Medical Policy Group, November 2008 (3)

Medical Policy Administration Committee, December 2008

Available for comment December 5, 2008-January 19, 2009

Medical Policy Group, September 2010

Medical Policy Administration Committee, October 2010

Available for comment October 21 – December 6, 2010

Medical Policy Group, November 2010 (1) Key Points updated

Medical Policy Group, October 2015 (6):  Updates to Key Points, Coding and References; no change to policy statement.  Active policy but no longer scheduled for regular literature reviews and updates.

Medical Policy Group, December 2019 (6): Updates to Description, Key Points, Practice Guidelines, Key Words (perceptual dysfunction) and References. No change to policy intent.

Medical Policy Group, March 2021 (9): Updates to Description, Key Points, References. Policy statement updated to remove “not medically necessary,” no change to policy intent. Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, November 2021 (9): 2022 Annual Coding Update Revised CPT code 92065 to remove "pleoptic training" from descriptor.

Medical Policy Group, March 2022 (9): Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Updated Description and Key Points.

Medical Policy Group, March 2023 (9): Update to Key Points, Benefit Application and added CPT code 92066 to the Current Coding section. Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, April 2024 (9): Reviewed by consensus. Minor updates to Key Points, Benefit Application, and References. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.