Aetna Commercial Clinical Policy

Aetna Low Vision Programs Form

Effective Date

11/13/2001

Last Reviewed

07/28/2023

Original Document

  Reference



Background for this Policy

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

    Scope of Policy

    This Clinical Policy Bulletin addresses low vision programs.

    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.

    • 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.