Policy Statements

Overview

AAPOS has made a variety of policy statements on various aspects of pediatric ophthalmology. It is very helpful when communicating with third party carriers such as insurance companies to enclose a copy of these policy statements to "back up" the claims you are making regarding issues such as amblyopia and adult strabismus.

Documentation

SEC Policy Statement: Reimbursements for Children with Negative Findings in Pediatric Eye Exams

This policy statement advocates for appropriate reimbursement for pediatric eye examinations that result in negative findings. It highlights the complexity and necessity of these evaluations, which often require extensive time, testing, and expertise to rule out serious conditions. The statement calls for recognition of the medical necessity of these exams, ensuring that reimbursement reflects the comprehensive care provided, regardless of whether a definitive diagnosis is made.

Policy Statement | April 7, 2024


SEC Policy Statement: Reimbursements for Exams Under Anesthesia

This policy statement advocates for appropriate reimbursement of exams under anesthesia (EUAs) performed alongside surgical procedures when sedation is necessary. It emphasizes the medical necessity of EUAs for certain patients and the importance of unbundling necessary diagnostic tests. The statement also calls for consistent reimbursement across all medical settings, coverage for required postoperative care, and full-value payment for multiple procedures performed on the same day.

Policy Statement | February 20, 2024


AAPOS Policy Statement: Refractions In Children

This policy statement emphasizes the medical necessity of refraction in children as a critical diagnostic test for detecting and treating conditions like amblyopia and strabismus. It clarifies that refraction is not included in standard ophthalmology examination or evaluation/management (E/M) codes and should be separately documented and reimbursed under CPT code 92015. The statement asserts that refractions in children are essential for preventing lifelong vision loss and should be recognized as a reimbursable service.

Policy Statement | November 16, 2023


Sensorimotor Examination

This policy statement affirms the medical necessity and separate reimbursement of sensorimotor examinations (CPT 92060) for evaluating ocular misalignment and binocular function abnormalities. It emphasizes that these exams require additional time, expertise, and measurements beyond standard eye exams or evaluation/management (E/M) visits. The statement outlines documentation requirements, scenarios requiring a physician's order, and the need for formal interpretation. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) asserts that sensorimotor exams should be recognized as distinct, reimbursable services by all insurers.

Policy Statement | July 2021


Vigabatrin: The Problem of Monitoring for Peripheral Vision Loss in Children

This policy statement addresses the challenges of monitoring peripheral vision loss in children treated with Vigabatrin, an anti-epileptic drug known to cause retinal toxicity. It highlights the limitations of traditional visual field testing in young, nonverbal patients and suggests alternative monitoring methods, such as serial fundus examinations. The statement emphasizes the need for collaboration between ophthalmologists, neurologists, and families to balance seizure control with potential vision risks and calls for further research to improve early detection of Vigabatrin-induced visual changes.

Policy Statement | July 2017


Medical Need for Glasses

This policy statement emphasizes the medical necessity of glasses for children to treat and prevent vision loss from conditions such as amblyopia, strabismus, aphakia, and significant refractive errors. It highlights the importance of timely prescription and replacement to support normal visual, social, and intellectual development. The statement underscores that delayed access to appropriate glasses can lead to permanent vision impairment, making them essential for a child’s overall well-being.

Policy Statement | May 2017


Pathology Exclusions for Muscle Resection Specimens Policy Statement

This policy statement advocates for the exclusion of extraocular muscle resection specimens from mandatory pathological examination requirements, as they are typically histologically normal in cases of comitant strabismus. It emphasizes that such examinations are usually unnecessary and impose additional costs. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) supports allowing surgeons to request pathology only when deemed clinically necessary.

Policy Statement | May 2017


Amblyopia is a Medical Condition

This joint policy statement by the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology asserts that amblyopia is a medical condition requiring treatment. It highlights that amblyopia, a preventable and treatable form of vision loss, is caused by developmental abnormalities in the brain's vision centers and emphasizes the importance of early diagnosis and intervention to prevent permanent visual impairment. The statement also notes that preschool vision screening can identify risk factors, and optical correction may be part of the treatment plan.

Joint Statement | April 2017


Aphakic Lenses

This policy statement emphasizes the necessity of urgent optical treatment following cataract surgery in children to prevent permanent visual impairment. It highlights the importance of individualized optical correction, including aphakic contact lenses, glasses, or intraocular lenses, and stresses the need for frequent adjustments as children grow. The statement advocates for insurance coverage of these medically necessary optical treatments to ensure proper visual habilitation and prevent amblyopia.

Policy Statement | March 2017


Medically Necessary Eye Examinations for Children Who Have Failed Vision Screening

This policy statement asserts that comprehensive eye examinations are medically necessary for children who fail vision screenings, even if no ocular pathology is found. Early detection of eye diseases and vision disorders, such as amblyopia and strabismus, is crucial for preventing irreversible vision loss. The statement emphasizes that such exams are essential for ensuring proper eye health and are not considered routine care.

Policy Statement | March 2017


Need for Vitrectomy When Performing Pediatric Cataract Surgery

This policy statement outlines the necessity of performing a vitrectomy during pediatric cataract surgery to ensure the best visual outcome for children, especially those under 9 years of age, who are at risk of developing secondary cataracts. The vitrectomy procedure involves the excision of the posterior lens capsule, anterior hyaloid membrane, and anterior vitreous, and is typically planned prior to cataract surgery to prevent permanent vision loss. The statement emphasizes that vitrectomy is a medically necessary procedure and should be reimbursed accordingly.

Policy Statement | March 2017


Orthoptists as Physician Extenders

This policy statement recognizes orthoptists as valuable physician extenders in the field of pediatric ophthalmology, particularly for treating strabismus and binocular vision disorders. Orthoptists are qualified to independently evaluate and treat patients with eye movement and binocular vision issues. They are considered similar to nurse practitioners and physician assistants in terms of their role in providing care under the supervision of an ophthalmologist. The policy highlights the extensive education and certification required for orthoptists, and it defines the supervision levels under Medicare for procedures like sensorimotor exams and orthoptic training.

Policy Statement | March 2017


Refraction as Part of the Eye Exam

This policy statement outlines the importance of refraction in diagnosing and treating childhood eye diseases and vision abnormalities. Refraction helps determine refractive errors, which, if untreated, can lead to conditions like amblyopia and strabismus, potentially resulting in permanent vision loss. The policy clarifies that refraction is not included in ophthalmology exam codes or Evaluation/Management (E/M) procedures and must be reported separately using CPT® code 92015. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) recognizes refractions in children as medically necessary and eligible for reimbursement as a separate service.

Policy Statement | March 2017


Procedures for the Evaluation of the Visual System by Pediatricians

This clinical report from the American Academy of Pediatrics provides guidelines for pediatricians on evaluating the visual system in children, emphasizing early vision screening to detect disorders like amblyopia, strabismus, and refractive errors. It outlines recommended screening methods, including red reflex testing, ocular alignment assessment, and instrument-based screening, to ensure timely diagnosis and intervention. The report highlights the importance of regular vision assessments from infancy through adolescence to prevent lifelong visual impairment.

Clinical Report | January 2016


Visual System Assessment in Infants, Children, and Young Adults by Pediatricians

This policy statement emphasizes the importance of regular visual system assessments in infants, children, and young adults to detect and address vision abnormalities early. It recommends newborn eye examinations, instrument-based vision screening between 12 months and 3 years, and direct visual acuity testing starting at age 4. The statement highlights the role of pediatricians in identifying conditions such as amblyopia, strabismus, and other ocular disorders, ensuring timely referrals for specialized care to prevent long-term visual impairment.

Policy Statement | January 2016


Protective Eyewear

This joint policy statement from the American Academy of Pediatrics and the American Academy of Ophthalmology strongly recommends protective eyewear for young athletes participating in sports with a risk of eye injury. It emphasizes that protective eyewear should be mandatory for athletes who are functionally one-eyed or have a history of eye surgery or trauma. The statement outlines the risks associated with various sports, provides guidelines for selecting appropriate protective eyewear, and stresses the importance of compliance to prevent serious eye injuries.

Joint Policy Statement | 2013


Instrument-Based Pediatric Vision Screening

This policy statement supports the use of instrument-based vision screening, such as photoscreening and autorefraction, for detecting amblyogenic risk factors in young children. These automated screening methods require minimal cooperation, making them especially useful for preverbal, preliterate, or developmentally delayed children. The statement emphasizes the benefits of early detection but acknowledges that widespread adoption may be hindered by third-party payment policies.

Joint Policy Statement | October 29, 2012


Adult Strabismus Surgery

This policy statement addresses the treatment of adult strabismus, a condition characterized by abnormal binocular alignment of the eyes, and highlights the benefits of strabismus surgery for adults. Surgery can alleviate symptoms like diplopia (double vision), visual confusion, and abnormal head posture, while also restoring binocular vision, improving visual fields, and enhancing psychosocial function. Indications for surgery include diplopia, visual confusion, difficulty with prism glasses or patching, and the need for enhanced vocational or social functioning. The statement stresses that successful surgery can greatly improve quality of life by addressing visual and psychosocial disabilities caused by strabismus, and recommends that adults with this condition consult with their ophthalmologist for further evaluation.

Policy Statement | May 2012


Learning Disabilities, Dyslexia and Vision

This technical report clarifies that dyslexia and other learning disabilities are primarily language-based disorders, not visual problems. It emphasizes that while vision issues can interfere with reading, children with learning disabilities generally have normal visual function. The statement strongly asserts that scientific evidence does not support the use of vision therapy, eye exercises, or specialized lenses as treatments for dyslexia, advocating instead for evidence-based educational interventions that focus on phonemic awareness, decoding, fluency, and comprehension

Joint Technical Report | February 28, 2011


Learning Disabilities, Dyslexia and Vision

This policy statement emphasizes that learning disabilities, including dyslexia, are complex neurocognitive disorders with genetic and brain-based origins, not caused by vision problems. While vision issues can impact learning, they are not the root cause of dyslexia, and treatments such as eye exercises, vision therapy, or tinted lenses lack scientific support. The statement advocates for early identification and evidence-based educational interventions focused on phonemic awareness, decoding, fluency, and comprehension to support children with reading disabilities.

Joint Policy Statement | 2009


“Computer Vision Syndrome” and Children

This policy statement clarifies that there is no scientific evidence linking screen time to vision problems in children, as their eyes are naturally flexible and can easily adapt to visual environments. While limiting screen time is important for other health reasons, such as preventing obesity and attention-related disorders, there is no indication that it affects the developing visual system. The American Academy of Pediatrics recommends screen time limitations for young children to support their overall development.

Policy Statement


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