CG-MED-102 Dichoptic Digital Therapy for Amblyopia

This policy addresses dichoptic digital therapy (e.g., Luminopia One, CureSight, RevitalVision) for treating amblyopia. Anthem covers an initial 12-month trial when the patient is 4 to <14 years old with anisometropic, small-angle (≤10 prism diopters) strabismic, or mixed-mechanism amblyopia; has failed a 6-month trial of patching or atropine (or cannot use atropine); and, for CureSight/RevitalVision, passes a 10-minute in-clinic eye-tracking performance test (validity >90% with successful calibration). Therapy is not medically necessary when these criteria are not met.

"An initial 12-month trial of dichoptic digital therapy is consideredmedically necessarywhen the following criteria are met:"

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