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Figure.
Clinical criteria for Medicare coverage for vision assistive equipment (VAE). ADLs indicates activities of daily living.

Clinical criteria for Medicare coverage for vision assistive equipment (VAE). ADLs indicates activities of daily living.

Table 1. 
Examples of Vision Assistive Equipment for Activities of Daily Living and Instrumental Activities of Daily Living
Examples of Vision Assistive Equipment for Activities of Daily Living and Instrumental Activities of Daily Living
Table 2. 
Analysis of Medicare Beneficiaries Who Would Qualify for and Benefit From Vision Assistive Equipment (VAE)
Analysis of Medicare Beneficiaries Who Would Qualify for and Benefit From Vision Assistive Equipment (VAE)
Table 3. 
Case Summaries Illustrating Application of the Vision Assistive Equipment (VAE) Algorithma
Case Summaries Illustrating Application of the Vision Assistive Equipment (VAE) Algorithma
1.
Centers for Disease Control and Prevention (CDC), Prevalence of disabilities and associated health conditions among adults—United States, 1999 [published correction appears in MMWR Morb Mortal Wkly Rep. 2001;50(8):149]. MMWR Morb Mortal Wkly Rep 2001;50 (7) 120- 125
PubMed
2.
Sloan  FAOstermann  JBrown  DSLee  PP Effects of changes in self-reported vision on cognitive, affective, and functional status and living arrangements among the elderly. Am J Ophthalmol 2005;140 (4) 618- 627
PubMedArticle
3.
Massof  RWHsu  CTBaker  FH  et al.  Visual disability variables. I: the importance and difficulty of activity goals for a sample of low-vision patients. Arch Phys Med Rehabil 2005;86 (5) 946- 953
PubMedArticle
4.
Patino  CM McKean-Cowdin  RAzen  SPAllison  JCChoudhury  FVarma  RLos Angeles Latino Eye Study Group, Central and peripheral visual impairment and the risk of falls and falls with injury. Ophthalmology 2010;117 (2) 199- 206, e1
PubMedArticle
5.
Cacciatore  FAbete  PMaggi  S  et al.  Disability and 6-year mortality in elderly population: role of visual impairment. Aging Clin Exp Res 2004;16 (5) 382- 388
PubMedArticle
6.
Pedula  KLColeman  ALHillier  TA  et al. Study of Osteoporotic Fractures Research Group, Visual acuity, contrast sensitivity, and mortality in older women: study of osteoporotic fractures. J Am Geriatr Soc 2006;54 (12) 1871- 1877
PubMedArticle
7.
Morse  ARYatzkan  EBerberich  BArons  RR Acute care hospital utilization by patients with visual impairment. Arch Ophthalmol 1999;117 (7) 943- 949
PubMedArticle
8.
Morse  ARPyenson  BS Medical care cost of Medicare/Medicaid beneficiaries with vision loss. Ophthalmic Epidemiol 2009;16 (1) 50- 57
PubMedArticle
9.
McCarty  CANanjan  MBTaylor  HR Vision impairment predicts 5 year mortality. Br J Ophthalmol 2001;85 (3) 322- 326
PubMedArticle
10.
Vu  HTKeeffe  JE McCarty  CATaylor  HR Impact of unilateral and bilateral vision loss on quality of life. Br J Ophthalmol 2005;89 (3) 360- 363
PubMedArticle
11.
Javitt  JCZhou  ZWillke  RJ Association between vision loss and higher medical care costs in Medicare beneficiaries costs are greater for those with progressive vision loss. Ophthalmology 2007;114 (2) 238- 245
PubMedArticle
12.
World Health Organization, International Classification of Diseases, Ninth Revision (ICD-9).  Geneva, Switzerland World Health Organization1977;
13.
Centers for Medicare and Medicaid Services, US Department of Health and Human Services, Program memorandum: intermediaries/carriers: provider education article: Medicare coverage of rehabilitation services for beneficiaries with vision impairment. May 29, 2002. Transmittal AB-02-078. http://146.123.140.205/Transmittals/downloads/AB02078.pdf. Accessed July 27, 2010
14.
Massof  RW A model of the prevalence and incidence of low vision and blindness among adults in the U.S. Optom Vis Sci 2002;79 (1) 31- 38
PubMedArticle
15.
US Census Bureau, Annual estimates of the resident population by sex and 5-year age groups for the United States: April 1, 2000, to July 1, 2009. http://www.census.gov/popest/national/asrh/NC-EST2009-sa.html Accessed July 26, 2010
16.
Centers for Medicare and Medicare, US Department of Health and Human Services, Medicare enrollment: national trends, 1966-2008. www.cms.hhs.gov/MedicareEnRpts/Downloads/HISMI08.pdf. Accessed January 29, 2010
17.
Fries  JF Aging, natural death, and the compression of morbidity. N Engl J Med 1980;303 (3) 130- 135
PubMedArticle
18.
Manton  KGGu  X Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999. Proc Natl Acad Sci U S A 2001;98 (11) 6354- 6359
PubMedArticle
19.
Freedman  VAMartin  LGSchoeni  RF Recent trends in disability and functioning among older adults in the United States: a systematic review. JAMA 2002;288 (24) 3137- 3146
PubMedArticle
20.
Lee  DJArheart  KLLam  BL  et al.  Trends in reported visual impairment in United States adults. Ophthalmic Epidemiol 2009;16 (1) 42- 49
PubMedArticle
21.
Bachman  DLWolf  PALinn  RT  et al.  Incidence of dementia and probable Alzheimer's disease in a general population: the Framingham Study. Neurology 1993;43 (3, pt 1) 515- 519
PubMedArticle
22.
Plassman  BLLanga  KMFisher  GG  et al.  Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 2007;29 (1-2) 125- 132
PubMedArticle
23.
Williams  GR Incidence and characteristics of total stroke in the United States. BMC Neurology 2001;1e2http://www.biomedcentral.com/1471-2377/1/2. Accessed February 21, 2010Article
24.
American Heart Association, Heart Disease and Stroke Statistics: 2009 Update (At-a-Glance Version).  Dallas, TX American Heart Association2009;
25.
Pambakian  ALKennard  C Can visual function be restored in patients with homonymous hemianopia? Br J Ophthalmol 1997;81 (4) 324- 328
PubMedArticle
26.
Skidmore  ERWhyte  EMHolm  MB  et al.  Cognitive and affective predictors of rehabilitation participation after stroke. Arch Phys Med Rehabil 2010;91 (2) 203- 207
PubMedArticle
27.
Plassman  BLLanga  KMFisher  GG  et al.  Prevalence of cognitive impairment without dementia in the United States. Ann Intern Med 2008;148 (6) 427- 434
PubMedArticle
28.
Morse  ARTeresi  JRosenthal  BHolmes  D Yatzkan  ES Visual acuity assessment in persons with dementia. J Vis Impair Blind 1994;98 (9) 560- 566
29.
Horowitz  A Vision impairment and functional disability among nursing home residents. Gerontologist 1994;34 (3) 316- 323
PubMedArticle
30.
van Splunder  JStilma  JSBernsen  RMDEvenhuis  HM Prevalence of visual impairment in adults with intellectual disabilities in the Netherlands: cross-sectional study. Eye (Lond) 2006;20 (9) 1004- 1010
PubMedArticle
31.
Rogers  M Vision impairment in Liverpool: prevalence and morbidity. Arch Dis Child 1996;74 (4) 299- 303
PubMedArticle
32.
Warburg  M Visual impairment among people with developmental delay. J Intellect Disabil Res 1994;38 (pt 4) 423- 432
PubMedArticle
33.
Sloan  FABrown  DSCarlisle  ESPicone  GALee  PP Monitoring visual status: why patients do or do not comply with practice guidelines. Health Serv Res 2004;39 (5) 1429- 1448
PubMedArticle
34.
Ellish  NJRoyak-Schaler  RPassmore  SRHigginbotham  EJ Knowledge, attitudes, and beliefs about dilated eye examinations among African-Americans. Invest Ophthalmol Vis Sci 2007;48 (5) 1989- 1994
PubMedArticle
35.
Moss  SEKlein  RKlein  BEK Factors associated with having eye examinations in persons with diabetes. Arch Fam Med 1995;4 (6) 529- 534
PubMedArticle
36.
Brechner  RJCowie  CCHowie  LJHerman  WHWill  JCHarris  MI Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA 1993;270 (14) 1714- 1718
PubMedArticle
37.
Granström  PA Progression of visual field defects in glaucoma: relation to compliance with pilocarpine therapy. Arch Ophthalmol 1985;103 (4) 529- 531
PubMedArticle
38.
Friedman  DS Introduction: new insights on enhancing adherence to topical glaucoma medications. Ophthalmology 2009;116 (11) ((suppl)) S29
PubMedArticle
39.
Trauzettel-Klosinski  S Rehabilitation for visual disorders. J Neuroophthalmol 2010;30 (1) 73- 84
PubMedArticle
40.
Rossetti  YRode  GPisella  L  et al.  Prism adaptation to a rightward optical deviation rehabilitates left hemispatial neglect. Nature 1998;395 (6698) 166- 169
PubMedArticle
41.
Bowers  ARKeeney  KPeli  E Community-based trial of a peripheral prism visual field expansion device for hemianopia. Arch Ophthalmol 2008;126 (5) 657- 664
PubMedArticle
42.
American Academy of Ophthalmology, Preferred Practice Patterns: vision rehabilitation for adults PPP.  October2007;http://www.aao.org/ppp. Accessed January 21, 2010
43.
American Optometric Association, Optometric Clinical Practice Guideline: Care of the Patients With Visual Impairment.  St Louis, MO American Optometric Association2007;
44.
Warren  M Low Vision: Occupational Therapy Intervention With the Older Adult: A Self-Paced Clinical Course From AOTA.  Bethesda, MD American Occupational Therapy Association2000;
45.
US Department of Veterans Affairs, Veterans Health Administration handbook, 1173.5 (1173.05), October 27, 2008. http://www.prosthetics.va.gov/PSAS_handbooks.asp. Accessed July 30, 2010
46.
Stelmack  JATang  XCReda  DJRinne  SMancil  RMMassof  RWLOVIT Study Group, Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008;126 (5) 608- 617
PubMedArticle
47.
Stroupe  KTStelmack  JATang  XC  et al.  Economic evaluation of blind rehabilitation for veterans with macular diseases in the Department of Veterans Affairs. Ophthalmic Epidemiol 2008;15 (2) 84- 91
PubMedArticle
48.
 Exclusions From Coverage and Medicare as a Secondary Payer 42 USC 1395y §1862(a)(7) (2009)
49.
Scheiman  MScheiman  MWhittaker  SG Low Vision Rehabilitation: A Practical Guide for Occupational Therapists.  Thorofare, NJ Slack Inc2002;
50.
Warren  M Occupational therapy practice guidelines for adults with low vision. Lieberman  DThe AOTA Practice Guideline Series. Bethesda, MD American Occupational Therapy Association2001;1- 25
51.
Wainapel  SFKwon  YSFazzari  PJ Severe visual impairment on a rehabilitation unit: incidence and implications. Arch Phys Med Rehabil 1989;70 (6) 439- 441
PubMedArticle
52.
Carlson  MAFanchiang  SPZemke  RClark  F A meta-analysis of the effectiveness of occupational therapy for older persons. Am J Occup Ther 1996;50 (2) 89- 98
PubMedArticle
53.
Girdler  SJBoldy  DPDhaliwal  SSCrowley  MPacker  TL Vision self-management for older adults: a randomised controlled trial. Br J Ophthalmol 2010;94 (2) 223- 228
PubMedArticle
54.
Clark  FAzen  SPZemke  R  et al.  Occupational therapy for independent-living older adults: a randomized controlled trial. JAMA 1997;278 (16) 1321- 1326
PubMedArticle
55.
Cope  DN The effectiveness of traumatic brain injury rehabilitation: a review. Brain Inj 1995;9 (7) 649- 670
PubMedArticle
56.
Steultjens  EMDekker  JBouter  LMLeemrijse  CJvan den Ende  CH Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews. Clin Rehabil 2005;19 (3) 247- 254
PubMedArticle
57.
Brownson  CAHoerger  TJFisher  EBKilpatrick  KE Cost-effectiveness of diabetes self-management programs in community primary care settings. Diabetes Educ 2009;35 (5) 761- 769
PubMedArticle
58.
Norris  SLNichols  PJCaspersen  CJ  et al.  Increasing diabetes self-management education in community settings: a systematic review. Am J Prev Med 2002;22 (4) ((suppl)) 39- 66
PubMedArticle
59.
Lorig  KGonzales  V Community-based diabetes self-management education: definition and case study. Diabetes Spectrum. 2000;13(4):e234. http://journal.diabetes.org/diabetesspectrum/00v13n4/page234.asp. Accessed July 27, 2010
60.
Cate  YRichards  L Relationship between performance on tests of basic visual functions and visual-perceptual processing in persons after brain injury. Am J Occup Ther 2000;54 (3) 326- 334
PubMedArticle
61.
Colenbrander  A Assessment of functional vision and its rehabilitation. Acta Ophthalmol 2010;88 (2) 163- 173
PubMedArticle
62.
 Currier v Leavitt, 490 F Supp 2d 12 (D Me 2007) 
63.
 Currier v Thompson, 369 F Supp 2d 65 (D Me 2005) 
64.
 Davidson v Thompson, No. CIV 04-32 LFG, slip op (D NM 2004) 
65.
 Collins v Thompson, No. 2:03-cv-265-FtM-29SPC, slip op (MD Fla 2004) 
66.
Centers for Medicare and Medicaid Services, US Department of Health and Human Services, Mobility assistive equipment. http://www.cms.hhs.gov/CoverageGenInfo/06_wheelchair.asp. Accessed July 27, 2010
67.
Centers for Medicare and Medicaid Services, US Department of Health and Human Services, Medicare coverage of power mobility devices (PMDs): power wheelchairs and power operated vehicles (POVs).  March2009;http://www.cms.hhs.gov/mlnproducts/downloads/pmdfactsheet07_quark19.pdf. Accessed July 27, 2010
Special Article
October 11, 2010

Medicare Coverage for Vision Assistive Equipment

Author Affiliations

Author Affiliations: The Jewish Guild for the Blind (Drs Morse and Cole and Ms O’Hearn), Department of Rehabilitation Medicine, New York–Presbyterian Hospital (Dr Hsu), Department of Ophthalmology, Columbia University College of Physicians and Surgeons (Drs Morse and Cole) and Lighthouse International (Dr Faye), New York, and Departments of Physical Medicine and Rehabilitation, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx (Dr Wainapel), New York; Lions Vision Research and Rehabilitation Center, Wilmer Ophthalmological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Massof); Department of Ophthalmology, Center for Vision Rehabilitation and Research, Henry Ford Health System, Detroit, Michigan (Dr Mogk); and Vision Rehabilitation Service, Massachusetts Eye and Ear Infirmary, Boston (Dr Jackson).

Arch Ophthalmol. 2010;128(10):1350-1357. doi:10.1001/archophthalmol.2010.228
Abstract

Vision loss that cannot be corrected medically, surgically, or by refractive means is considered low vision. Low vision often results in impairment of daily activities, loss of independence, increased risk of fractures, excess health care expense, and reduced physical functioning, quality of life, and life expectancy. Vision rehabilitation can enable more independent functioning for individuals with low vision. The Centers for Medicare and Medicaid Services recognizes the importance of rehabilitation for achieving medically necessary goals but has denied Medicare coverage for vision assistive equipment that is necessary to complete these goals, although they provide coverage for assistive equipment to provide compensation for other disabilities. We believe that this is discriminatory and does not comport with congressional intent. The Centers for Medicare and Medicaid Services should provide coverage for vision assistive equipment, allowing beneficiaries with vision loss to benefit fully from Medicare-covered rehabilitation to achieve the cost-effective results of these services.

Never tell a patient there is nothing more to be done. Rehabilitation is always an option.—Helen Keller

Visual impairment and blindness are among the 10 most common causes of disability in the United States.1 They often result in reduced physical functioning and in impaired activities of daily living (ADLs), instrumental activities of daily living (IADLs), and safety in moving about the environment.2 Affected ADLs include dressing, bathing, eating, transferring, and toileting. Affected IADLs include more complex but essential daily tasks such as preparing meals, taking medications, using the telephone, self-health monitoring (eg, using devices such as glucometers or sphygmomanometers), and providing wound and ostomy care.3 Vision loss is associated with increased falls (resulting in injury or fractures)46 and health care costs7,8 and with decreased life expectancy9 and quality of life.10 Progression of vision loss has been associated with greater risk of injury and with skilled nursing facility or other long-term care use.11

THE VISION REHABILITATION PROCESS

When vision loss cannot be corrected medically, surgically, or by refractive means, the result is a diagnosis of visual impairment, ranging from low vision to blindness. The ADLs and IADLs that are impaired or impeded by vision loss may be improved through vision rehabilitation (VR) in combination with vision assistive equipment (VAE) (Table 1). Rehabilitation and assistive devices can help and are often essential to improve performance of ADLs and IADLs and to enable more independent functioning for individuals with low vision, including most patients having a diagnosis of legal blindness, defined as visual acuity of 20/200 or less in the better eye with correction or as visual fields of 20° or less (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM ]12 codes 369.xx). The first step in rehabilitation of low vision is to maximize vision by any medical, surgical, or refractive error correction that is required. The second step is to compensate for the remaining and uncorrectable visual impairment with VAE. The third step is rehabilitation training to learn proper use of VAE, in addition to other adaptive devices and techniques, to accomplish ADLs and IADLs.

The Centers for Medicare and Medicaid Services (CMS) has recognized the importance of providing rehabilitation coverage for beneficiaries with vision loss on the same basis as for beneficiaries with other conditions. Rehabilitation improves performance in ADLs and IADLs to achieve goals that are medically necessary. In 2002, the CMS provided the following guidance to Medicare fiscal intermediaries:

Medicare beneficiaries who are blind or visually impaired are eligible for physician-prescribed rehabilitation services. . . on the same basis as beneficiaries with other medical conditions that result in reduced physical functioning. . . . [including] rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical and should be performed by an occupational or physical therapist. . . . [A]ll rehabilitation services to beneficiaries with a primary vision impairment diagnosis must be provided pursuant to a written treatment plan established by a Medicare physician, and implemented by approved Medicare providers (occupational or physical therapists) or incident to physician services. . . . [P]rograms/services for beneficiaries with vision impairment may include Medicare covered therapeutic services [such as] Mobility; Activities of Daily Living; and Other rehabilitation goals that are medically necessary.13

To be eligible to receive Medicare coverage for VR, a beneficiary must have at least moderate impairment in both eyes, defined as visual acuity of less than 20/60 after correction of refractive error (ICD-9-CM code 369.25). In addition, beneficiaries with central scotomas (code 368.41), generalized visual field contraction or constriction (code 368.45), homonymous bilateral field defects (code 368.46), and heteronymous bilateral visual field defects (code 368.47) are eligible for rehabilitation services coverage, even if their visual acuity is 20/60 or better.

INCIDENCE AND PREVALENCE OF LOW VISION AND USE OF VAE

For 2000, in analyzing each of the major studies that evaluated incidence and prevalence of blindness and low vision, Massof14 estimated that 1 255 000 individuals 65 years or older (3.6%) had visual acuity of less than 20/70 and that vision loss in 15% to 20% was from cataracts and was potentially reversible. US Census Bureau15 data for 2000 indicated that there were 35 076 990 individuals 65 years or older, of whom 34 252 835 (97.7%) were enrolled in Medicare, and 1 048 050 (3.0%) of these had uncorrectable visual acuity of less than 20/60 (low vision or blindness) after eliminating those with cataracts. By 2008, there were 37 584 186 individuals 65 years or older who had enrolled in Medicare.16 Using the schema by Massof,14 after eliminating those whose vision loss was due to cataracts and was correctable, we estimate the prevalence of low vision and blindness to be 1 150 075 among Medicare beneficiaries 65 years or older and the overall annual incidence among this group to be approximately 250 000 cases.

Because of the development and use of more effective treatments (and possibly as a function of the compression of morbidity17), the rates of low vision and blindness over the next several decades may plateau and even decline. An acceleration in the overall rate of decline of long-term disability prevalence (from 0.6% in 1984 to 2.2% in 2004-2005)18,19 is also reflected in downward trends of progressive vision loss, especially among the approximately 35% of community-dwelling adults who visited an eye care professional within the last year.20

The incidence rates of stroke, dementia or other cognitive impairments, and other neurologic or psychiatric disorders increase sharply with age.2123 For example, for each decade after age 55 years, the risk of stroke more than doubles,24 and 30% of all patients with stroke have visual field deficits.25 Unless vision loss among patients with stroke is addressed through rehabilitation, their participation in ADLs and IADLs may be reduced, while their risk for more long-term and severe disability increases.26 In addition, the incidence rate of dementia doubles with each 5-year age group after age 65 years, and more than 22% of the US population older than 71 years has cognitive impairment without dementia, which increases their risk of dementia.27 Patients with dementia and vision loss may have excess deficits in their functional behaviors if their vision loss is inadequately addressed.28,29 Setting forth the complex interactions of disorders that could affect ability to benefit from VR and VAE is beyond the scope of the present article; however, it is clear that overall morbidity, especially cognitive impairment, can decrease the efficacy of VR, while addressing vision loss may improve the efficacy of overall rehabilitation. Considering these factors, a substantial number of new Medicare enrollees aged 65 years and increasing each year thereafter would be unable to benefit from VR or VAE.

The remaining Medicare cohort with low vision or blindness comprises beneficiaries younger than 65 years who are enrolled in Medicare because of disability status rather than age. In 2008, of the total number of Medicare beneficiaries 83.0% (37 584 186 of 45 301 837) were enrolled because of their age, while 17.0% (7 717 651) were enrolled because of disability status.16 Among these 7.7 million younger Medicare beneficiaries, the prevalence of low vision (1.5%) and blindness (0.65%) sums to 2.15%.16 Although there is evidence that among those with other disabilities the prevalence of vision loss may be somewhat higher, the data are inconclusive.3032 For each year from 2005 to 2008, the number of Medicare beneficiaries younger than 65 years with disabilities increased by a mean of 271 063. We estimate that the upper boundary for the annual incidence of blindness and low vision among new Medicare beneficiaries younger than 65 years is less than 5830 (not more than the overall prevalence of 2.15%) for this group. Many of these individuals qualify for Medicare because of traumatic brain injury or congenital, developmental, multiple, or other acquired disabilities, and it is likely that a significant number may be unable to benefit from VR and VAE.

Among all Medicare beneficiaries, we estimate that in 2008 there were 256 000 new beneficiaries with low vision or blindness (Table 2). There are no accurate data on the extent of comorbidities among these beneficiaries that would limit the usefulness of VR; however, we believe that between 128 000 and 192 000 may qualify for and be able to benefit from VR and VAE.

Patients who believe that a physician visit is likely to lead to a therapeutic and helpful intervention seem to be more likely to seek care. Sloan et al33 found that, while patients having diagnosed diabetes were likely to have follow-up vision examinations (with the frequency increasing with the severity of retinopathy), patients with diagnosed age-related macular degeneration (before the introduction of anti–vascular endothelial growth factor therapy) had less frequent eye examinations than before their diagnosis; the authors suggest that diagnosis of an “incurable” disease leads to a decrease in visits for eye care. Not surprisingly, costs (including copayments, eyeglasses, and medications) have also been documented as a barrier to effective eye care.34 Overall, compliance with eye care practice guidelines is about 50%. For example, compliance with eye care recommendations for patients with diabetes averages about 50%,35,36 although regular examinations and laser treatment are effective in minimizing the progression and complications of diabetic retinopathy. Similarly, adherence with a medication regimen and regular examinations for patients with glaucoma are usually effective in controlling progression of the disease and in preserving vision.37,38 For most patients, VR and VAE training following a thorough low vision examination will require 6 to 12 visits of 1 to 2 hours each over 4 to 12 weeks. Because of the potential for gain in independent function, we expect that at least half of the eligible Medicare beneficiaries (64 000-96 000) will initiate VR services. However, because of the intensity of the therapy and training visits required, we anticipate that only about half of those who begin VR (approximately 40 000 Medicare beneficiaries) will complete a plan of care that includes VAE.

MEDICARE COVERAGE FOR VR AND VAE

Because many types of VAE contain a lens, the CMS classifies them as eyeglasses and denies coverage under Medicare's established policy of denying coverage for eyeglasses. This interpretation is misguided and does not represent congressional intent; there is a clear distinction between VAE and devices used for correction of refractive error or presbyopia such as conventional or reading eyeglasses, the use of which generally results in normal or near-normal vision. Refraction is the correction of abnormalities in the ability of the eye to focus clearly at a distance, while presbyopia is an inability of the eye to change focus to see adequately at close-up range; these deficits are corrected using eyeglasses, which generally results in normal or near-normal vision. Optical VAE compensates for visual impairments; it does not correct them. Optical VAE works by the following means: (1) provides magnification to compensate for reduced best-corrected visual acuity and may be used in conjunction with eccentric viewing techniques; (2) increases contrast, which is essential for many individuals with low vision; (3) controls illumination to compensate for photophobia and for visual adaptation and glare recovery disorders; and (4) expands the viewable visual field,39 which may be accomplished with prisms and can be particularly useful in addressing vision loss for patients with hemispatial neglect40 or hemianopia,41 common consequences of stroke or brain injury.

Preliminary data from an ongoing study with a national sample that includes more than 600 patients who were referred for VR suggest that about one-third of the referred patients have visual acuities of 20/60 or better and were referred because of constricted visual fields, poor contrast sensitivity, or central scotomas (J. E. Goldstein, OD, and the Low Vision Research Network Study Group, oral communication, March 6, 2010). Of the remaining patients, about two-thirds have visual acuities of 20/60 to 20/200, while the other one-third have visual acuities of 20/200 or worse and are considered legally blind. The mean per capita cost of VAE is estimated to be approximately $800.

Although physician-prescribed rehabilitation services for qualifying beneficiaries are covered by Medicare, VAE that is needed to benefit effectively from rehabilitation by beneficiaries with vision loss has been excluded from coverage. A Medicare beneficiary with vision loss who qualifies for Medicare-covered rehabilitation services should also qualify for VAE necessary to implement their rehabilitation care plan and to enable them to use the skills and techniques that have been acquired through the rehabilitation process. The American Academy of Ophthalmology,42 American Optometric Association,43 and American Occupational Therapy Association44 recognize the therapeutic value of VR and the use of VAE. Moreover, the United States Department of Veterans Affairs considers VAE as prosthetic devices and provides them to veterans with visual impairments.45 A recently completed randomized controlled trial, the Veterans Affairs Low Vision Intervention Trial, provided strong evidence of the effectiveness of rehabilitation for low vision.46 The trial also showed that VAE combined with rehabilitation of low vision is cost- effective.47 Although recognizing the need for and value of VR, the CMS has consistently denied coverage for VAE, relying on 42 USC 1395y §1862(a)(7), which explicitly excludes from coverage

eyeglasses (other than eyewear described in §1861(s)(8)) or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine the refractive state of the eyes.”48

Exceptions exist for eyeglasses, contact lenses, or intraocular lens implants supplied to Medicare beneficiaries with aphakic or pseudophakic disease, in which case the lens of the eye has been surgically removed, most often because of cataracts.

Before 2002, most VR services were provided through a vocational rehabilitation model by teachers who were unlicensed, mostly uncertified and working outside of traditional health care settings. Since then, the establishment of Medicare coverage for rehabilitation services to beneficiaries with vision loss on the same basis as to beneficiaries with other medical conditions that result in reduced physical functioning12 has resulted in a burgeoning interest in VR. There has also been a growing recognition that longer life expectancy will increase the prevalence of visual impairments from age-related eye diseases. These changes shift the responsibility for rehabilitation of individuals with vision loss (ie, VR) to the medical rehabilitation community, particularly occupational therapists49,50 already working with patients whose vision loss resulted from disorders such as stroke. Wainapel et al51 observed that 5.8% of admissions to a hospital rehabilitation inpatient unit met criteria for legal blindness and that an additional 1% met criteria for low vision. They commented presciently that

health care professionals working in rehabilitation should become more familiar with, and proficient in, the basic principles and treatment techniques used in the rehabilitation of visually impaired persons.51(p440)

There is compelling evidence that VR is effective in improving health, quality of life, daily functioning, and self-sufficiency in ADLs and IADLs5254 for patients with traumatic brain injury,55 stroke,56 and diabetes,5759 as well as age-related macular degeneration39 and other common causes of vision loss. Deficits in visual perception have been associated with loss of independence in self-care,60 while improved ability to function independently can result in decreased dependence. For example, patients with diabetes and vision impairment who learn to self-monitor their glucose levels and independently administer insulin through rehabilitation and diabetes self-management education may reduce the need for home health care or clinic visits for medication management. Enhancing functional vision through rehabilitation decreases disability and increases functional ability61 by improving a patient's ability to perform essential life functions (ADLs and IADLs), which can reduce the cost of subsequent Medicare-covered health care services.

The position held by the CMS of providing coverage for rehabilitation services but not for the necessary equipment (VAE) is paradoxical; a beneficiary may receive VR care and be considered successfully rehabilitated and able, with an appropriate VAE, to perform ADLs and IADLs necessary for reasonable self-sufficiency. If a VAE is not provided, beneficiaries are unable to perform these tasks and are relegated to an unnecessarily dependent status. This is akin to providing a wheelchair and a home attendant to an individual with an amputated limb, while denying coverage for a lower extremity prosthesis that would allow for safe independent ambulation. This does not reflect congressional intent in the wording of the eyeglass exclusion in the Medicare statute.48 Several federal courts have held that the CMS interpretation is wrong. These decisions support the position that the eyeglass exclusion is just that—an exclusion of Medicare coverage for conventional eyeglasses—and should not be broadly construed to include anything else. A federal district court in Maine held that a video monitor, commonly referred to as a closed-circuit television, that magnifies the size of print and is used by a beneficiary with macular degeneration to read prescriptions, therapy instructions, and financial documents and to engage in ADLs must be covered as durable medical equipment.62 Previously, the district court in that case had rejected the argument by the CMS that the device was excluded because it fell within the statutory exclusion for eyeglasses.63 Of particular significance, the judge held that the eyeglass exclusion in the Medicare statute excludes coverage only for routine eyeglasses but not more for elaborate treatments, citing 2 other court cases that reached the same conclusion regarding coverage for low vision technology.64,65

PROPOSED MEDICARE COVERAGE CRITERIA FOR VAE

The flowchart in the Figure lists our proposed clinical criteria for Medicare coverage for VAE to restore a beneficiary's ability to participate effectively in ADLs and summarizes an analysis that is consistent with other Medicare coverage algorithms.66,67 Detailed examples of flowchart applications are available in an appendix on request from the author, and case summaries are given in Table 3. By using the flowchart algorithm together with the questions enumerated herein, beneficiaries with vision loss will be treated consistently with other Medicare beneficiaries who require assistive equipment because of other disabilities.

1.  Does the beneficiary have a vision limitation that significantly impairs his or her ability to participate in 1 or more ADLs? A vision limitation is one that:

 (a) Prevents the beneficiary from accomplishing ADLs or IADLs entirely, or

 (b) Places the beneficiary at a reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in ADLs or IADLs, or

 (c) Prevents the beneficiary from completing ADLs or IADLs within a reasonable time frame.

2.  Can the functional vision deficit be sufficiently resolved by correcting the beneficiary's refractive error? If so, vision assistive devices are unnecessary and are ineligible for coverage.

3.  Are the enhancements provided by a VAE needed to allow the beneficiary to participate in 1 or more ADLs? The type of VAE should be appropriate for the degree of the beneficiary's functional vision impairments and his or her individual needs and goals.

4.  Are there other conditions that limit the beneficiary's ability to participate in ADLs at home? For these beneficiaries, even with VAE, they might not be able to participate in ADLs if the other conditions prevent effective use of the VAE or allow reasonable completion of the tasks even with VAE. Some examples are significant impairment of cognition or judgment and neurologic or orthopedic impairment.

5.  If other limitations or comorbidities exist, can they be ameliorated or compensated sufficiently such that the provision of VAE will be reasonably expected to significantly enhance and improve the beneficiary's ability to perform or use assistance to participate in ADLs?

 (a) If the amelioration or compensation requires the beneficiary's compliance, noncompliance can be a basis for denial of VAE.

 (b) Partial compliance may result in adequate amelioration or compensation to permit the appropriate use of VAE.

6.  Does the beneficiary demonstrate the capability and willingness to use VAE safely and consistently? Safety considerations, including risk to the beneficiary or others, and a history of unsafe behavior should be considered. For example, a device intended to assist in reading may create an unsafe condition if used when walking outdoors.

CONCLUSIONS

Medicare policy should be revised and clarified to eliminate discrimination against beneficiaries with vision loss and to provide coverage for VAE and devices. We are not suggesting that Medicare should cover devices or equipment used to correct refractive errors or presbyopia, consistent with the historical exclusion of these devices from Medicare coverage. For this reason, it is important to clearly distinguish between plus lenses used to correct presbyopia and plus lenses used for magnification that is required to compensate for visual acuity loss. We propose that an equivalent addition of 6 diopters (D) to the beneficiary's distance correction (ie, “add”) is the appropriate boundary to define lenses used for magnification by beneficiaries who meet the Medicare coverage criteria for their VR. Standard presbyopia corrections reach a maximum of 4-D add and enable people to read standard print, which is equivalent to a visual acuity of approximately 20/50. Stronger lenses are referred to as microscopes and provide extra magnification as vision decreases. Magnification to compensate for loss of visual acuity to worse than 20/60, a moderate vision impairment, requires lenses (ie, microscopes) of at least ×1.5 magnification, which is equivalent to a 6- D add. These lenses should be eligible for Medicare coverage when prescribed for beneficiaries with moderate vision impairment or worse. Although patients with beginning vision loss might benefit from weaker adds (between +4 and +6), these would not be eligible for coverage because the best-corrected visual acuity at initial examination would be 20/60 or better.

Devices prescribed for purposes other than correction of refractive error or presbyopia should be eligible for Medicare coverage on the same basis as other assistive equipment. We believe that this is in keeping with congressional intent in the Medicare statute and would ensure that Medicare beneficiaries with vision impairment have the same access to Medicare-covered services as beneficiaries with other disabilities. Coverage should be determined using the criteria delineated in the flowchart herein and the accompanying questions. Medicare should provide coverage for VAE to allow beneficiaries with vision loss to benefit fully from Medicare-covered rehabilitation to achieve the proven outcomes and cost-effective results of these services.

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Article Information

Correspondence: Alan R. Morse, JD, PhD, The Jewish Guild for the Blind, 15 W 65th St, New York, NY 10023 (armorse@jgb.org).

Submitted for Publication: March 29, 2010; final revision received May 31, 2010; accepted June 2, 2010.

Financial Disclosure: None reported.

References
1.
Centers for Disease Control and Prevention (CDC), Prevalence of disabilities and associated health conditions among adults—United States, 1999 [published correction appears in MMWR Morb Mortal Wkly Rep. 2001;50(8):149]. MMWR Morb Mortal Wkly Rep 2001;50 (7) 120- 125
PubMed
2.
Sloan  FAOstermann  JBrown  DSLee  PP Effects of changes in self-reported vision on cognitive, affective, and functional status and living arrangements among the elderly. Am J Ophthalmol 2005;140 (4) 618- 627
PubMedArticle
3.
Massof  RWHsu  CTBaker  FH  et al.  Visual disability variables. I: the importance and difficulty of activity goals for a sample of low-vision patients. Arch Phys Med Rehabil 2005;86 (5) 946- 953
PubMedArticle
4.
Patino  CM McKean-Cowdin  RAzen  SPAllison  JCChoudhury  FVarma  RLos Angeles Latino Eye Study Group, Central and peripheral visual impairment and the risk of falls and falls with injury. Ophthalmology 2010;117 (2) 199- 206, e1
PubMedArticle
5.
Cacciatore  FAbete  PMaggi  S  et al.  Disability and 6-year mortality in elderly population: role of visual impairment. Aging Clin Exp Res 2004;16 (5) 382- 388
PubMedArticle
6.
Pedula  KLColeman  ALHillier  TA  et al. Study of Osteoporotic Fractures Research Group, Visual acuity, contrast sensitivity, and mortality in older women: study of osteoporotic fractures. J Am Geriatr Soc 2006;54 (12) 1871- 1877
PubMedArticle
7.
Morse  ARYatzkan  EBerberich  BArons  RR Acute care hospital utilization by patients with visual impairment. Arch Ophthalmol 1999;117 (7) 943- 949
PubMedArticle
8.
Morse  ARPyenson  BS Medical care cost of Medicare/Medicaid beneficiaries with vision loss. Ophthalmic Epidemiol 2009;16 (1) 50- 57
PubMedArticle
9.
McCarty  CANanjan  MBTaylor  HR Vision impairment predicts 5 year mortality. Br J Ophthalmol 2001;85 (3) 322- 326
PubMedArticle
10.
Vu  HTKeeffe  JE McCarty  CATaylor  HR Impact of unilateral and bilateral vision loss on quality of life. Br J Ophthalmol 2005;89 (3) 360- 363
PubMedArticle
11.
Javitt  JCZhou  ZWillke  RJ Association between vision loss and higher medical care costs in Medicare beneficiaries costs are greater for those with progressive vision loss. Ophthalmology 2007;114 (2) 238- 245
PubMedArticle
12.
World Health Organization, International Classification of Diseases, Ninth Revision (ICD-9).  Geneva, Switzerland World Health Organization1977;
13.
Centers for Medicare and Medicaid Services, US Department of Health and Human Services, Program memorandum: intermediaries/carriers: provider education article: Medicare coverage of rehabilitation services for beneficiaries with vision impairment. May 29, 2002. Transmittal AB-02-078. http://146.123.140.205/Transmittals/downloads/AB02078.pdf. Accessed July 27, 2010
14.
Massof  RW A model of the prevalence and incidence of low vision and blindness among adults in the U.S. Optom Vis Sci 2002;79 (1) 31- 38
PubMedArticle
15.
US Census Bureau, Annual estimates of the resident population by sex and 5-year age groups for the United States: April 1, 2000, to July 1, 2009. http://www.census.gov/popest/national/asrh/NC-EST2009-sa.html Accessed July 26, 2010
16.
Centers for Medicare and Medicare, US Department of Health and Human Services, Medicare enrollment: national trends, 1966-2008. www.cms.hhs.gov/MedicareEnRpts/Downloads/HISMI08.pdf. Accessed January 29, 2010
17.
Fries  JF Aging, natural death, and the compression of morbidity. N Engl J Med 1980;303 (3) 130- 135
PubMedArticle
18.
Manton  KGGu  X Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999. Proc Natl Acad Sci U S A 2001;98 (11) 6354- 6359
PubMedArticle
19.
Freedman  VAMartin  LGSchoeni  RF Recent trends in disability and functioning among older adults in the United States: a systematic review. JAMA 2002;288 (24) 3137- 3146
PubMedArticle
20.
Lee  DJArheart  KLLam  BL  et al.  Trends in reported visual impairment in United States adults. Ophthalmic Epidemiol 2009;16 (1) 42- 49
PubMedArticle
21.
Bachman  DLWolf  PALinn  RT  et al.  Incidence of dementia and probable Alzheimer's disease in a general population: the Framingham Study. Neurology 1993;43 (3, pt 1) 515- 519
PubMedArticle
22.
Plassman  BLLanga  KMFisher  GG  et al.  Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 2007;29 (1-2) 125- 132
PubMedArticle
23.
Williams  GR Incidence and characteristics of total stroke in the United States. BMC Neurology 2001;1e2http://www.biomedcentral.com/1471-2377/1/2. Accessed February 21, 2010Article
24.
American Heart Association, Heart Disease and Stroke Statistics: 2009 Update (At-a-Glance Version).  Dallas, TX American Heart Association2009;
25.
Pambakian  ALKennard  C Can visual function be restored in patients with homonymous hemianopia? Br J Ophthalmol 1997;81 (4) 324- 328
PubMedArticle
26.
Skidmore  ERWhyte  EMHolm  MB  et al.  Cognitive and affective predictors of rehabilitation participation after stroke. Arch Phys Med Rehabil 2010;91 (2) 203- 207
PubMedArticle
27.
Plassman  BLLanga  KMFisher  GG  et al.  Prevalence of cognitive impairment without dementia in the United States. Ann Intern Med 2008;148 (6) 427- 434
PubMedArticle
28.
Morse  ARTeresi  JRosenthal  BHolmes  D Yatzkan  ES Visual acuity assessment in persons with dementia. J Vis Impair Blind 1994;98 (9) 560- 566
29.
Horowitz  A Vision impairment and functional disability among nursing home residents. Gerontologist 1994;34 (3) 316- 323
PubMedArticle
30.
van Splunder  JStilma  JSBernsen  RMDEvenhuis  HM Prevalence of visual impairment in adults with intellectual disabilities in the Netherlands: cross-sectional study. Eye (Lond) 2006;20 (9) 1004- 1010
PubMedArticle
31.
Rogers  M Vision impairment in Liverpool: prevalence and morbidity. Arch Dis Child 1996;74 (4) 299- 303
PubMedArticle
32.
Warburg  M Visual impairment among people with developmental delay. J Intellect Disabil Res 1994;38 (pt 4) 423- 432
PubMedArticle
33.
Sloan  FABrown  DSCarlisle  ESPicone  GALee  PP Monitoring visual status: why patients do or do not comply with practice guidelines. Health Serv Res 2004;39 (5) 1429- 1448
PubMedArticle
34.
Ellish  NJRoyak-Schaler  RPassmore  SRHigginbotham  EJ Knowledge, attitudes, and beliefs about dilated eye examinations among African-Americans. Invest Ophthalmol Vis Sci 2007;48 (5) 1989- 1994
PubMedArticle
35.
Moss  SEKlein  RKlein  BEK Factors associated with having eye examinations in persons with diabetes. Arch Fam Med 1995;4 (6) 529- 534
PubMedArticle
36.
Brechner  RJCowie  CCHowie  LJHerman  WHWill  JCHarris  MI Ophthalmic examination among adults with diagnosed diabetes mellitus. JAMA 1993;270 (14) 1714- 1718
PubMedArticle
37.
Granström  PA Progression of visual field defects in glaucoma: relation to compliance with pilocarpine therapy. Arch Ophthalmol 1985;103 (4) 529- 531
PubMedArticle
38.
Friedman  DS Introduction: new insights on enhancing adherence to topical glaucoma medications. Ophthalmology 2009;116 (11) ((suppl)) S29
PubMedArticle
39.
Trauzettel-Klosinski  S Rehabilitation for visual disorders. J Neuroophthalmol 2010;30 (1) 73- 84
PubMedArticle
40.
Rossetti  YRode  GPisella  L  et al.  Prism adaptation to a rightward optical deviation rehabilitates left hemispatial neglect. Nature 1998;395 (6698) 166- 169
PubMedArticle
41.
Bowers  ARKeeney  KPeli  E Community-based trial of a peripheral prism visual field expansion device for hemianopia. Arch Ophthalmol 2008;126 (5) 657- 664
PubMedArticle
42.
American Academy of Ophthalmology, Preferred Practice Patterns: vision rehabilitation for adults PPP.  October2007;http://www.aao.org/ppp. Accessed January 21, 2010
43.
American Optometric Association, Optometric Clinical Practice Guideline: Care of the Patients With Visual Impairment.  St Louis, MO American Optometric Association2007;
44.
Warren  M Low Vision: Occupational Therapy Intervention With the Older Adult: A Self-Paced Clinical Course From AOTA.  Bethesda, MD American Occupational Therapy Association2000;
45.
US Department of Veterans Affairs, Veterans Health Administration handbook, 1173.5 (1173.05), October 27, 2008. http://www.prosthetics.va.gov/PSAS_handbooks.asp. Accessed July 30, 2010
46.
Stelmack  JATang  XCReda  DJRinne  SMancil  RMMassof  RWLOVIT Study Group, Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008;126 (5) 608- 617
PubMedArticle
47.
Stroupe  KTStelmack  JATang  XC  et al.  Economic evaluation of blind rehabilitation for veterans with macular diseases in the Department of Veterans Affairs. Ophthalmic Epidemiol 2008;15 (2) 84- 91
PubMedArticle
48.
 Exclusions From Coverage and Medicare as a Secondary Payer 42 USC 1395y §1862(a)(7) (2009)
49.
Scheiman  MScheiman  MWhittaker  SG Low Vision Rehabilitation: A Practical Guide for Occupational Therapists.  Thorofare, NJ Slack Inc2002;
50.
Warren  M Occupational therapy practice guidelines for adults with low vision. Lieberman  DThe AOTA Practice Guideline Series. Bethesda, MD American Occupational Therapy Association2001;1- 25
51.
Wainapel  SFKwon  YSFazzari  PJ Severe visual impairment on a rehabilitation unit: incidence and implications. Arch Phys Med Rehabil 1989;70 (6) 439- 441
PubMedArticle
52.
Carlson  MAFanchiang  SPZemke  RClark  F A meta-analysis of the effectiveness of occupational therapy for older persons. Am J Occup Ther 1996;50 (2) 89- 98
PubMedArticle
53.
Girdler  SJBoldy  DPDhaliwal  SSCrowley  MPacker  TL Vision self-management for older adults: a randomised controlled trial. Br J Ophthalmol 2010;94 (2) 223- 228
PubMedArticle
54.
Clark  FAzen  SPZemke  R  et al.  Occupational therapy for independent-living older adults: a randomized controlled trial. JAMA 1997;278 (16) 1321- 1326
PubMedArticle
55.
Cope  DN The effectiveness of traumatic brain injury rehabilitation: a review. Brain Inj 1995;9 (7) 649- 670
PubMedArticle
56.
Steultjens  EMDekker  JBouter  LMLeemrijse  CJvan den Ende  CH Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews. Clin Rehabil 2005;19 (3) 247- 254
PubMedArticle
57.
Brownson  CAHoerger  TJFisher  EBKilpatrick  KE Cost-effectiveness of diabetes self-management programs in community primary care settings. Diabetes Educ 2009;35 (5) 761- 769
PubMedArticle
58.
Norris  SLNichols  PJCaspersen  CJ  et al.  Increasing diabetes self-management education in community settings: a systematic review. Am J Prev Med 2002;22 (4) ((suppl)) 39- 66
PubMedArticle
59.
Lorig  KGonzales  V Community-based diabetes self-management education: definition and case study. Diabetes Spectrum. 2000;13(4):e234. http://journal.diabetes.org/diabetesspectrum/00v13n4/page234.asp. Accessed July 27, 2010
60.
Cate  YRichards  L Relationship between performance on tests of basic visual functions and visual-perceptual processing in persons after brain injury. Am J Occup Ther 2000;54 (3) 326- 334
PubMedArticle
61.
Colenbrander  A Assessment of functional vision and its rehabilitation. Acta Ophthalmol 2010;88 (2) 163- 173
PubMedArticle
62.
 Currier v Leavitt, 490 F Supp 2d 12 (D Me 2007) 
63.
 Currier v Thompson, 369 F Supp 2d 65 (D Me 2005) 
64.
 Davidson v Thompson, No. CIV 04-32 LFG, slip op (D NM 2004) 
65.
 Collins v Thompson, No. 2:03-cv-265-FtM-29SPC, slip op (MD Fla 2004) 
66.
Centers for Medicare and Medicaid Services, US Department of Health and Human Services, Mobility assistive equipment. http://www.cms.hhs.gov/CoverageGenInfo/06_wheelchair.asp. Accessed July 27, 2010
67.
Centers for Medicare and Medicaid Services, US Department of Health and Human Services, Medicare coverage of power mobility devices (PMDs): power wheelchairs and power operated vehicles (POVs).  March2009;http://www.cms.hhs.gov/mlnproducts/downloads/pmdfactsheet07_quark19.pdf. Accessed July 27, 2010
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