Vision Therapy for Vision: 18.4% of denials overturned
In 38 California IMR decisions from 2002 to 2023, reviewers overturned 7 (18.4%). In the last five years: 0.0% of 2. 20 were medical-necessity disputes, 18 experimental/investigational.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2023 | 2 | 0.0% |
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Published evidence citedThe findings refer to peer-reviewed or published evidence. | 16 | 0.0% | 18.4% |
| Experimental or investigationalThe findings discuss whether the treatment is experimental. | 5 | 0.0% | 18.4% |
| Prior therapies failedThe findings mention treatments that were tried without adequate response. | 4 | 25.0% | 18.4% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“The patient’s parent has requested authorization and coverage for 36 vision therapy sessions. The American Optometric Association (AOA) states that, “studies suggest that vision therapy is effective in altering accommodation, with a resultant change in amplitude and facility and a decrease in symptoms.” Studies have demonstrated that vergence therapy improves vergence ability, and that the effects persist over time. Saccadic …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for vision therapy with a developmental optometrist. Findings: Three medical professional reviewers found that there is sufficient support for the requested services in this patient’s case. The Convergence Insufficiency Treatment Trial showed that office-based vision therapy is an effective treatment for convergence insufficiency. Long-term findings …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for vision care therapy for treatment of the enrollee’s vision problems. Findings: The physician reviewer found that Evidence based research demonstrates that vision therapy has a high success rate in the treatment and management of vergence dysfunction. Office-based vision therapy has been shown to have …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for vision therapy. There is currently a paucity of peer-reviewed medical studies which support vision therapy. According to a medical study, visual problems do not cause dyslexia and scientific evidence does not support the efficacy of eye exercises, vision therapy, …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Vision Therapy denials for Vision overturned?
In 38 California IMR decisions from 2002 to 2023, reviewers overturned 7 (18.4%). In the last five years: 0.0% of 2. 20 were medical-necessity disputes, 18 experimental/investigational.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.