CurrentAetnaPolicy 0566

Strabismus Repair

Clinical coverage policy for surgical repair of strabismus, specifying medical necessity criteria, investigational uses, and cosmetic exclusions; applies to Aetna members and providers submitting claims for strabismus surgery.

Policy Summary

PayerAetna

PolicyStrabismus Repair

Policy CodePolicy 0566

Change TypeMinor / No material coverage change

Effective DateSep 25, 2001

Next Review DateJun 13, 2024

Key ActionFor adults, document diplopia or impaired peripheral vision from esotropia and that restoring alignment will restore fusion to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Adults ≥18age group with specified medical necessity criteria

Childrensurgery considered medically necessary

2experimental uses listed

Multiple codescoding guidance present

07/28/2023last review

06/13/2024

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Coverage Criteria

Medical Necessity - Adults

Aetna considers strabismus repair medically necessary for adults 18 years of age or older only if BOTH of the following are met:

Adult medical necessity criteria

AND 2) Restoration of alignment will restore ability to maintain fusion.

Aetna considers repair of strabismus to be cosmetic when there is no expected improvement of fusion. In such cases the procedure does not meet the policy’s medical necessity criteria for adults because restoring the ability to maintain fusion is required for coverage.

The use of amniotic membrane in strabismus surgery is considered experimental and investigational because its clinical value for this indication has not been established.

The use of the Ologen biodegradable collagen matrix implant to reduce adhesions in restrictive strabismus is considered experimental and investigational because its effectiveness for this purpose has not been established.

This Clinical Policy Bulletin provides a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and cannot guarantee outcomes; participating providers are independent contractors. Treating providers are responsible for medical advice and treatment, and the bulletin may be updated and is subject to change.

Coding

Covered CPT Codes (when selection criteria met)CPTCovered

67311	Strabismus surgery, recession or resection procedure: one horizontal muscle
67312	two horizontal muscles
67314	one vertical muscle (excluding superior oblique)
67316	two or more vertical muscles (excluding superior oblique)
67318	Strabismus surgery, any procedure, superior oblique muscle
67320	Transposition procedure, any extraocular muscle (specify) (List separately in addition to code for primary procedure)
67331	Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in addition to code for primary procedure)
67332	Strabismus surgery on patient with scarring of extraocular muscles or restrictive myopathy (List separately in addition to code for primary procedure)
67334	Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure)
67335	Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery)

1–10 of 13

1/2

CPT Codes not covered for indications listed in the CPBCPTNot Covered

65778-65779	Placement of amniotic membrane on the ocular surface
65780	Ocular surface reconstruction; amniotic membrane transplantation, multiple layers

Implant not codedmixedExperimental

Ologen

Biodegradable collagen matrix implant - no specific code

Covered ICD-10 Codes (when selection criteria met)ICD-10Covered

H49.00-H49.9	Paralytic strabismus
H50.00-H50.9	Other strabismus

ICD-10 Codes not covered for indications listed in the CPBICD-10Not Covered

Z41.1

Encounter for cosmetic surgery

Provider Actions and Authorization

Prior Authorization

Code-based authorization note

Selection of listed CPT and ICD-10 codes for strabismus surgery must meet the policy's medical necessity criteria (adult criteria: documented diplopia or impairment of peripheral vision due to esotropia, and documentation that restoration of alignment will restore fusion). Codes for amniotic membrane and Ologen collagen matrix implant are addressed as experimental/investigational and are not covered for the indications in this policy.

Affected CPT codes include 67311, 67312, 67314, 67316, 67318, 67320, 67331, 67332, 67334, 67335, 67340, 67343, 67345 (covered when medical necessity criteria met).
Amniotic membrane CPT/HCPCS (e.g., 65778-65780) and Ologen implant (no specific code) are considered experimental/investigational for these indications.

Note

No explicit denial triggers provided

No explicit administrative denial triggers are listed in the policy history or review notes; however, providers should ensure documentation meets the clinical criteria described in this CPB to avoid claim denials.

Policy history and review dates may affect prior authorization procedures — check current plan requirements.

Background

Strabismus is misalignment of the eyes due to imbalance of the extraocular muscles. The goals of strabismus surgery include restoring visual acuity, restoring or preserving binocular fusion, eliminating diplopia, and improving visual fields. In adults, documentation that diplopia or impaired peripheral vision from esotropia exists and that restoration of alignment will restore fusion is required for coverage. Surgical techniques vary (for example, recession and resection, transposition, exploration/repair, and procedures to address restrictive myopathy) and are selected based on the type and cause of the deviation.

Definitions

Strabismus

DefinitionStrabismus: inability of one eye to attain binocular vision with the other because of imbalances of the extraocular muscles.

Clinical significanceGoals of strabismus surgery include obtaining or improving fusion, eliminating diplopia and associated sensory adaptations, and improving visual fields.

Adult presentationIn adults, sudden-onset strabismus commonly follows head trauma, intracranial hemorrhage, or brain tumor and typically causes diplopia.

Pediatric considerationAdults with congenital strabismus often have amblyopia and correction is unlikely to achieve stereopsis and fusion.

Recession and resection

Recession (weaken)Recession weakens an extraocular muscle by detaching it at its insertion and reattaching it posteriorly to the sclera (distance not to exceed 8 mm for lateral rectus in exotropia examples).

Revision History

2023-07-28policy reviewLatest

Policy last reviewed on 07/28/2023.

2001-09-25effective date

Policy became effective on 09/25/2001.

2024-06-13scheduled next review

Next scheduled policy review on 06/13/2024.