Thursday, November 1, 2012

Why Vision Therapy Should Be Covered By Insurance: A Plea to Insurance Companies

I realize that the question “What is medically necessary?” is not easy to answer. Sometimes the answer isn’t a challenge, like when it pertains to treatment for ‘obvious’ medical issues. But sometimes the answer is less clear, like when it comes to chiropractic therapy, psychotherapy or vision therapy, the answer is less clear.

In this blog, I want to address the issue of vision therapy. I was born with strabismus, which most people recognize as a lazy eye. However, there’s much more behind strabismus than the physical affect of the disease. Strabismus causes one eye to turn off, forcing a person to rely on solely one eye. This, in turn, causes:

Lack of depth perception (which affects perception and driving)
Eye strain (which affects life in general)
Learning challenges (which makes it difficult to realize academic and athletic abilities)

All of these things, in conjunction with the physical effects of strabismus, lead to a key problem: depression. So, what I don’t understand is why my insurance company is perfectly okay with paying for me to see a therapist for multiple years so I can accept what’s wrong with me, rather than allowing me to spend 52 weeks total seeing a vision therapist to correct what’s wrong with me.

Allow me to share my story. I was born with a lazy eye as part of my strabismus. I had three cosmetically corrective surgeries throughout my childhood and none of them worked for an extended amount of time. Now, as an adult, I’m told more surgery is not an option because it’ll only make the problem worse (as I already have scar tissue in my eye prohibiting full movement), and aside from that, cosmetic surgery does not fix the underlying problem.

As much as I’d like to have the ‘magic’ surgery to correct the positioning of my eye, it doesn’t fix the following, which vision therapy does correct:

My depth perception
My eyes’ ability to work together
My ability to better interpret space and my surroundings
My ability to find a sustainable solution that won’t ‘fade’ in a few years
My ability to read without eye strain
My ability to live without constant headaches

What’s confusing to me is that my insurance company (Blue Cross Blue Shield Federal Employee Program) would be willing to pay for my strabismus treatment if I was under 18 years old. I’m not sure if this would cover vision therapy (I don’t think it would) but it would cover surgery. So here’s why this is inappropriate:

This makes surgery the better option for budget-conscious parents of children with strabismus. Surgery is NOT the answer. Well, surgery may be part of the answer, but it without vision therapy, it’s significantly less effective.
I’m being forced to pay out of pocket for vision therapy because of my parents’ mistakes. It is not my fault that as a child, I wasn’t given the option to attend vision therapy.
 
I have been forced to live my life plagued with depression because of strabismus. I didn’t even realize until recently the tie-in between my visual issues and depression. I thought:
 
I was simply not athletic. So, I couldn’t catch a softball. So what? I’m just not good at it. WRONG. I wasn’t able to see where the ball was in space and time.
I wasn’t a good dancer. Actually, that was because of my vision problems, too. I favored one side of my body based on my visual imbalance. Therefore, I never learned how to use my body as a whole and learn how to dance properly.
I didn’t pay attention while reading. I spent so much of my life reading paragraphs, then stopping to think about them and realizing that I’d retained practically nothing. Was it my inability to pay attention? NO. It was the way I learned to compensate and favor one eye, therefore changing the way I read. It’s still amazing to me how much anxiety I get when I have to read out loud because I do not read the way that normal people do.

Let’s not forget the constant self-consciousness that comes along with a lazy eye, even as an adult. I’m tired of being told “Oh, it gets less important as you get older.” REALLY? Is that the answer when a therapy that can fix the problem exists, but only if you have enough money to pay for it because insurance refuses to help?

I understand why insurance companies are hesitant to pay for vision therapy. There’s no ‘concrete’ evidence that it helps, unlike with more physical treatments. However, vision therapy has helped people improve their self esteem, improve in school, improve their driving, improve their overall vision and more. I know plenty of people have asked insurance companies for vision therapy – I’ve spoken to many who have fought the fight and lost. Yet for some reason, insurance companies refuse to believe that it helps, even though people have shelled out the cash and had proven results. My insurance company has denied me time and time again – despite the positive results, despite the letter of medical necessity, and despite the fact that I’ve proven that it has the ability to save them money on my coverage in the long run.

Below is an excerpt from the vision therapy appeal letter that I wrote to the Blue Cross Blue Shield Federal Employee Program. Even though I detailed the benefits of vision therapy, my appeal was denied.


I submitted my claims initially and was denied, so I got a letter of medical necessity to prove that this therapy is needed for my well being. The reasons I need this therapy are as follows:


Headache treatment. I am headache prone, and have prescription medication for the headaches I have on a constant basis. These headaches have decreased significantly since beginning vision therapy.
Treatment for eye strain. It does not seem that others have severe emotional distress when being required to read out loud. For me, this is difficult because of the extreme concentration that it requires. My eyes often tear up due to strain, and I trip on my words because of how much effort it takes to multi-task with reading out loud while maintaining focus on the letters. While reading normally is easy (aside from the blurring of the words and eye pain at times), reading out loud is nearly impossible because I have to take in the words one at a time or in small groups, rather than in large chunks as my eyes have been trained to do due to overcompensation for visual problems.
Emotional well-being. Having eyes that point in different directions has taken a toll on my self esteem, and because of this, I’ve been in and out of emotion-related therapy for since childhood. I’ve also taken antidepressants, which I was recently able to stop taking because of the improvement in my eyes, and therefore, my self esteem.
Personal safety. I do not see depth, which makes driving difficult for me. While I’ve never been involved in a moving violation because I’m extremely careful, the depth I am working on gaining through vision therapy will make me a better driver. It will also make me less accident prone, being that it will help me not walk into objects as much. (I know this sounds ridiculous but when you can’t tell how far an object is away from you, tripping on things is pretty common!)
Visual proficiency. Until beginning vision therapy, I did not properly use my peripheral vision. Through treatment, I’ve become better as looking all around, not just in front of me, allowing me to function better in society.
 
Vision therapy has begun to fix all of these issues with extreme success, and over the planned one-year course of treatment, it will continue to improve them even further.


If you are a potential vision therapy patient, or someone who has been denied coverage for vision therapy: Please comment on this blog post and share your story. If we stick together, we can make a difference, and hopefully we can get vision therapy coverage for those who need it in the future.

If you are a representative of an insurance company (specifically the company that denied my claims): Please email me at lessthanreality@gmail.com. Maybe we can make this right.

3 comments:

Anonymous said...

Kudos to you for this post and for hanging in there. I am a federal employee as well and my son, who is 12, was diagnosed with Intermittent Alternating Exotropia (a form of Strabismus). We began therapy and submitted claims to BCBS only to have the claims denied because the diagnosis and treatment code was not "specifically" Strabismus. I've pummeled them with medical coding index forms and articles all of which say his condition is indeed a form of Strabismus. I've even shoved the BCBS services and benefits booklet in their face pointing to pages 50-53 regarding coverage for vision therapy and pointing out the section stating BCBS covers non-surgical treatment for Strabismus and Amblyopia. All I want is to have the part of the benefit paid. The doctor is a non-participating provider, but comes highly recommended by his peers and the medical boards on pediatric optometry and Ophthalmology. I don't want to take this to an attorney, but I do love a good fight, especially when I know I am right. Good luck to you with your therapy! I wish you well!

JanG. said...

I, too, have been suffering with poor alignment of my eyes. BC/BS has turned me down for coverage of therapy and I cannot afford it. My quality of life has plummeted with squeezing headaches, and eye muscle pulling. My eyes have a shelf life of about 3 hours before the eye/head pain kicks in and progresses. I have felt as if I was truly standing atop a mountain screaming and noone could hear me.
Good luck to all who need help, for this is truly a long uphill battle.

Julie P said...

Amen...and to the insurance companies I say, "Where are the studies that prove that chiropractor treatments work? Why do you pay for that and not vision therapy?"
It breaks my heart how so many people can't get help because the insurance companies have to categorize all the medical problems and if you don't fit, you don't get help. God did not make us with a pre-arranged set of problems we could possibly develop. Every person is different and between genetic make-up and environmental differences, the potential # of problems we can develop is astronomical. Hence, a million and one possible diagnoses. One therapy might help one child, but the same therapy might not help another child even though their symptoms are similar. I believe we are as different in the way we express disease as we are in the way we respond to treatment. They need to stop expecting us to be cookie cutter people! But there ARE trends. And there are even studies. And there are getting to be more of them. Maybe one day they will listen to us.
My kids have convergence problems and I would love to get them help, but I'm anxious about starting this process. It stresses me out when I have to deal with something I don't agree with!
Thank you for articulating this issue so well! Keep up the fight!