A9292, Prescription digital visual therapy, software-only, fda cleared, per course of
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- CPT 0687T — Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session.
- CPT 0688T — Treatment of amblyopia using an online digital program; device supply, educational set-up, and assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month.
- CPT 0704T — Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment.
- CPT 0705T — Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days.
Key Coverage Criteria
- An initial 12-month trial of dichoptic digital therapy is consideredmedically necessarywhen the following criteria are met:
- Individual is age 4 through 13 years (at least 4 years 0 days and less than 14 years old);and
- The individual has anisometropic, small-angle (10 prism diopters or less) strabismic amblyopia or mixed-mechanism amblyopia;and
- There is failure to respond to a 6-month trial of patching or atropine (or contraindication/allergy/intolerance to atropine);and
- For CureSight and RevitalVision, the individual has passed a dedicated 10 minute in-clinic performance ability test to assure suitable eye tracking performance (validity of eye tracking data > 90% and successful calibration process);and
- Myopia, if present, is not greater than -6.00 D. spherical equivalent in either eye;and
3 Active Policies
ANTHEM-CG-MED-102, CG-MED-102 Dichoptic Digital Therapy for Amblyopia
REGENCE-MED175, Digital Therapeutic Products
REGENCE-MED175.04, Digital Therapeutic Products for Amblyopia
Related Codes
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