mp-334
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Visual Perceptual Training

Policy Number: MP-334

Latest Review Date: March 2021

Category:  Therapy                                                     

Policy Grade: Active Policy but no longer scheduled for Regular literature reviews and updates.

POLICY:

Visual perceptual training (VPT) is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE:

Visual Perceptual Training (VPT) is a treatment that has been proposed to treat learning disabilities.  In particular, this training was developed to treat visual perceptual and/or visual motor disabilities associated with learning disabilities.  The Handbook of Visual Perceptual Training defines visual perceptual disabilities 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.”  The authors note that “visual perceptual dysfunction represents an inefficient developmental functioning that is a handicap to cognitive process.  It is related to both cognition and emotional development.”  It is thought 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.  The authors note that concomitant factors of visual perceptual dysfunction may include short attention span, hyperactivity, distractibility, social adjustment difficulties, delayed motor perceptual ability, depressed academic achievement, inadequate body image, and low frustration level.

Visual perception training programs involve an integrated program involving speech and language activities, a wide range of sensory modalities, and visual-motor perceptual activities.  These activities include motor rhythm activities, body image training, spatial and directional relationships and should be built upon previous successes and move from concrete to abstract.  The Handbook recommends that after detection of the visual perceptual deficit, an individualized program be developed to meet the needs of the child.  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.  The Handbook recommends that a minimal length of time for this training to be 30 hours per child over a six-week period, with the daily period ranging from 30 minutes to an hour, or longer, depending on the child’s attention span.

Although vision perception training may include some exercises similar to vision therapy exercises, visual perceptual training should be distinguished from optometric vision therapy.  Visual perceptual training is directed toward perceptual dysfunctions that allegedly affect language and learning abilities, whereas 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.).  Patients receive vision therapy to treat visual disturbances that may theoretically cause developmental delays and learning disabilities, whereas patients may receive vision perception training to remedy developmental delays and learning disabilities without having any identified dysfunction of eye movements or focusing. Vision therapy is provided by an optometrist or eye care professionals.  Visual perceptual training is generally performed by psychologists, psychotherapists, occupational therapists, or other behavioral health professionals.

KEY POINTS:

The policy is updated regularly. The most recent literature review was performed through March 24, 2021.

Summary of Evidence

VPT is considered behavioral training and educational training in nature. The available data supporting the use of visual perceptual therapy to treat learning or developmental disabilities is weak and inconclusive, and derived primarily from uncontrolled or poorly controlled studies with significant methodological flaws. There are no well-designed clinical trials that indicate visual perceptual therapy is an effective treatment for learning disabilities or disorders. Well-designed randomized controlled studies are needed to determine this technology’s clinical utility. 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 Ophthalmology (AAO)

American Academy of Pediatric Ophthalmology and Strabismus (AAOPOS)

American Academy of Pediatrics (AAP)

In 1998, reaffirmed in 2011, a position statement by the American Academy of Pediatrics (AAP), the American Academy of Pediatric Ophthalmology and Strabismus (AAOPOS), and the American Academy of Ophthalmology (AAO) concluded that there is insufficient scientific evidence to support claims that academic abilities of children with learning disabilities can be improved with visual perceptual training.

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:  FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CURRENT CODING:

CPT Codes:  

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

92065 

Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

97533   

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

REFERENCES:

  1. American Association for Pediatric Ophthalmology and Strabismus.  Learning disabilities:  Information for parents.  2005 www.aapos.org/displaycommon.cfm?an=1&subarticlenbr=107.
  2. American Academy of Child and Adolescent Psychiatry.  Practice parameters for the assessment and treatment of children and adolescents with language and learning disorders.  1998, wwwaacap.org/galleries/practiceparameters/lang.pdf.
  3. American Academy of Ophthalmology Complementary Therapy Task Force.  Complementary therapy assessment:  Vision therapy for learning disabilities.  September 2001, one.aao.org/CE/practiceguidelines/therapy_content.aspx?cid=8021c013-7e4b-43f3-aa1a-698307ae526c.
  4. American Academy of Ophthalmology: Joint Statement: Learning Disabilities, Dyslexia, and Vision-Reaffirmed 2014. https://www.aao.org/clinical-statement/joint-statement-learning-disabilities-dyslexia-vis
  5. American Academy of Pediatrics, Council on Children with Disabilities, American Academy of Ophthalmology, et al. Joint statement--Learning disabilities, dyslexia, and vision. Pediatrics. Aug 2009; 124(2):837-844.
  6. 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): 1214-1219.
  7. American Optometric Association.  Pediatric eye and vision examination.  2nd ed., St. Louis, MO 2002.  www.aoa.org/documents/CPG-2.pdf.
  8. Anderson SW.  Neuropsychologic rehabilitation for visuoperceptual impairments.  Neurology Clinics, August 2003; 21(3): 729-740.
  9. 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.
  10. 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.
  11. Cunningham SA and Reagan CL.  Handbook of visual perceptual training.  Charles C. Thomas Publisher 1972, Springfield, Illinois.
  12. Fahle M.  Perceptual learning:  Specificity versus generalization.  Current Opinions Neurobiology, April 2005; 15(2): 154-160.
  13. 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.
  14. 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/.
  15. 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.
  16. Hicks C.  Remediating specific reading disabilities:  A review of approaches.  Journal of Research in Reading 1986; 9(1): 39-55.
  17. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
  18. Keogh BK, et al.  Vision training revisited.  Journal of Learning Disability, April 1985; 18(4): 228-236.
  19. Kronenberger WG, et al.  Learning disorders.  Neurology Clinics, November 2003; 21(4): 941-952.
  20. Marks HB. Evaluation of visual perceptual training for reading disabilities. R I Med J. 1970; 53(3):150-151 passim.
  21. Martin JC. Effects of visual perceptual training on visual perceptual skills and reading achievement. Percept Mot Skills. 1973; 37(2):564.
  22. Merck Manuals Online Medical Library.  Learning disabilities.  Merck and Co, August 2007, www.merck.com/mmpe/sec19/ch299/ch299d.html.
  23. 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.
  24. National Institute of Neurological Disorders and Strokes (NINDS).  NINDS Dyslexia Information Page.  Updated December 2007, www.ninds.nih.gov/disorders/dyslexia/hyslexia.htm.
  25. National Institute of Neurological Disorders and Strokes (NINDS).  NINDS Learning Disabilities Information Page.  Updated February 2007, www.ninds.nih.gov/disorders/learningdisabilities/learningdisabilites.htm.
  26. Olitsky SE, et al.  Reading disorders in children.  Pediatric Clinics of North America, February 2003; 50(1): 213-224.
  27. Rosen CL. An experimental study of visual perceptual training and reading achievement in first grade. Percept Mot Skills. 1966; 22(3):979-986.
  28. Schoeman OJ.  The therapeutic value of visual-perceptual training and its effect on scholastic achievement.  South African Medical Journal 1996; 86(8): 983.
  29. 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.
  30. Shaywitz SE.  Dyslexia.  NEJM, January 1998; 338(5): 307-312.
  31. Tannock R.  Learning disorders.  Kaplan & Saddock’s Comprehensive Textbook of Psychiatry, Chapter 35.  Philadelphia:  Lippincot, Williams and Wilkins 2005.
  32. 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.


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.