Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Strabismus surgery is designed to correct misalignment of the eyes. It is used to treat abnormal vision caused by the eyes not being aligned. In children with chronically misaligned eyes the brain will tend to choose one eye and ignore (suppress) the visual input from the other eye. In time, this results in an uncorrectable loss of vision in the ignored eye (amblyopia ex anopsia or “brain blindness of one eye”). Strabismus surgery is done early in life (while the visual pathways in the brain have not yet fully matured) to allow binocular vision (both eyes look at the same object) and to prevent amblyopia.

Adults (who already have fully mature visual pathways in the brain) cannot suppress signals from a misaligned eye and the result is double vision or visual confusion.  Eye misalignment in adults is often the result of an injury, stroke, or other medical condition. The primary purpose of strabismus surgery in adults is to reestablish normal eye alignment and eliminate double vision or visual confusion.  Small misalignments can be corrected with the use of prisms or special lenses but large deviations require surgery.

If a misaligned eye has little or no vision, there is no double vision or visual confusion to eliminate and restoring binocular vision is not an option.  The purpose of strabismus surgery in this situation is to improve appearance, not to restore visual function.  While a large, obvious deviation can be considered disfiguring and have negative psychosocial (and mental health) consequences, small-angle strabismus (a deviation of less than 15 degrees) or less is not disfiguring.  Therefore, if the misaligned eye has little or no vision and there is no double vision or visual confusion a deviation of less than 15 degrees is considered cosmetic and surgical intervention is not a covered benefit. 

Strabismus surgery requires pre-authorization in patients twelve years of age or older.

1. Covered strabismus surgery:

A.   Strabismus surgery is covered in children less than 12 years of age diagnosed with strabismus.

B.   Strabismus surgery requires pre-authorization for members 12 years of age and older. Strabismus surgery will be considered when the following criteria are met:

1)                Visual defect is documented and

2)                Visual defect is related to the strabismus or

3)                The misaligned eye has a deviation of 15 degrees or more.

1. Non-covered strabismus: surgery

A.   Cosmetic surgery to correct small-angle deviations of less than 15 degrees.

Codes Used In This BI:

Strabismus is ocular misalignment due to a number of different etiologies. The goals of strabismus surgery are to obtain normal visual acuity in each eye, to obtain or improve fusion, to eliminate any associated sensory adaptations or diplopia, and to improve visual fields.

In adults, the sudden onset of strabismus can result from ischemia, inflammation (such as in MS), head trauma, intracranial hemorrhage, or tumors. Adults with new-onset strabismus develop diplopia. Correction of strabismus in these situations should result in fusion of images and resolution of the diploplia. Adults with congenital strabismus, however, usually have failure of visual development (amblyopia) in the deviating eye; correction of ocular misalignment is unlikely to achieve stereopsis and fusion.

Visual Confusion:  Visual confusion, the perception of two different images superimposed onto the same space, is also a symptom of ocular misalignment.  This symptom can result from newly acquired strabismus or from change in the direction or amount of ocular misalignment in adults with childhood strabismus. Visual confusion is particularly debilitating when driving.  The affected individual may describe a car "crossing over the center line and coming straight at them," when, in fact, the brain is shifting the image of the car and superimposing it on the road ahead.  Surgical correction or reduction of the ocular deviation will usually relieve visual confusion.

 Restoration of Binocular Vision:  Whenever the eyes are not aligned, there is loss of binocular vision or fusion (unification of images) that lets us appreciate a more refined sense of depth perception in three dimensional spaces (stereopsis).  The majority of adults with childhood strabismus (as opposed to congenital strabismus resulting in amlyopia) who have had surgery to correct their strabismus as adults can regain fusion postoperatively. Even adults with long-standing sensory deprivation (because of wearing eye patches) have been shown to regain fusion after restoration of sight and alignment.

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