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:

1. Rustein RP. Care of the Patient with Strabismus: Exotropia and Esotropia. St. Louis, MO: American Consensus Panel on Care of the Patient With Strabismus; 1995:26-41.
2. Gill MK, Drummond GT. Indications and outcomes of strabismus repair in visually mature patients. Can J Ophthalmol. 1997; 32(7):436-440.
3. American Academy of Ophthalmology (AAO). Esotropia and exotropia. Preferred Practice Pattern. San Francisco, CA: AAO; September 2002.
4. Way LW, ed. Current Surgical Diagnosis and Treatment. Boston, MA: Appleton & Lange; 1994.
5. American Academy of Ophthalmology (AAO) and American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Policy Statement: Adult Strabismus Surgery. A Joint Statement of the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology. San Francisco, CA: AAO; April 2002. Available at: http://www.aao.org/aao/member/policy/adult.cfm
6. Ludwig IH, Brown MS. Flap tear of rectus muscles: An underlying cause of strabismus after orbital trauma. Ophthal Plast Reconstr Surg. 2002; 18(6):443-449; discussion 450.
7. Nickerson B. Nursing care of the pediatric patient following strabismus repair surgery. Insight. 2002; 27(3):64-65.
8. Yazdani A, Traboulsi EI. Classification and surgical management of patients with familial and sporadic forms of congenital fibrosis of the extra ocular muscles. Ophthalmology. 2004; 111(5):1035-1042.
9. Scheiman NM, et al. Randomized trial of treatment of amblyopia in children aged 7-17 years. Arch Ophthalmol. 2005; 123(4):437-447.
10. Kushner BJ and Morton GV. Postoperative binocularity in adults with longstanding strabismus. Ophthalmology. 1992; 99(3)316-319.
11. Mills MD, Coats DK, Donahue SP, and Wheeler DT. Strabismus surgery for adults: a report by the American Academy of Ophthalmology. Ophthalmology. 2004; 111(6):1255-1262.