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Strabismus Repair

Number: 0566

Policy

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

  1. Diplopia is documented, or there is an impairment of peripheral vision due to esotropia (marked turning inward of eye); and
  2. Restoration of alignment will restore ability to maintain fusion.

Aetna considers repair of strabismus cosmetic when there is no expected improvement of fusion.

Note: Strabismus surgery is considered medically necessary for children diagnosed with strabismus.

Background

Strabismus is an inability of one eye to attain binocular vision with the other because of imbalances of muscles of the eyeball.  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 usually follows head trauma, intra-cranial hemorrhage, or brain tumor.  Adults with new-onset strabismus develop diplopia.  Correction of strabismus should result in binocular vision and fusion of images.  Adults with congenital strabismus, however, usually have failure of visual development (amblyopia) in the deviating eye; correction of ocular mis-alignment is unlikely to achieve stereopsis and fusion.

Surgery for correction of strabismus consists of weakening or strengthening the extra-ocular muscles.  For correction of exotropia, the lateral rectus muscle is weakened by recession.  The muscle is detached at its insertion and then re-sewn posteriorly to the sclera at a distance not to exceed 8 mm from the original insertion while the medial rectus is cut at its insertion and a part of the muscle not to exceed 6 mm is resected.  The muscle is sutured to its original insertion.  The amount of recession and resection and the number of extra-ocular muscles resected or recessed are determined by the degree of ocular deviation (squint).  In patients with esotropia, the medial rectus is recessed and the lateral rectus is resected.  For vertical deviation, the vertical muscles are recessed, resected, tucked, or weakened by disinsertion (e.g., inferior oblique muscles).

CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
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 (eg, for paretic extraocular muscle), 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 (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmolopathy) (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)
+ 67340 Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for primary procedure)
67343 Release of extensive scar tissue without detaching extraocular muscle (separate procedure
67345 Chemodenervation of extraocular muscle
ICD-9 codes covered if selection criteria are met:
378.00 - 378.9 Strabismus and other disorders of binocular eye movements
ICD-9 codes not covered for indications listed in the CPB:
V50.1 Other plastic surgery for unacceptable cosmetic appearance
Other ICD-9 codes related to the CPB:
378.00 - 378.9 Strabismus and other disorders of binocular eye movements


The above policy is based on the following references:
    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. Accessed October 15, 2003.
    6. Beauchamp CL, Beauchamp GR, Stager DR, et al. The cost utility of strabismus surgery in adults. J AAPOS. 2006;10(5): 394-399.
    7. Hatt SR, Leske DA, Kirgis PA, et al. The effects of strabismus on quality of life in adults. Am J Ophthalmol. 2007;144(5):643-647.  
    8. Beauchamp GR, Felius J, Stager DR, Beauchamp CL. The utility of strabismus in adults. Trans Am Ophthalmol Soc. 2005;103:164-172.
    9. Jackson S, Harrad RA, Morris M, Rumsey N. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol. 2006;90(7):883-888.
    10. Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults--III. The effects on disability. J AAPOS. 2005;9(5):455-459.
    11. Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults--II. Patient and provider perspectives on the severity of adult strabismus and on outcome contributors. J AAPOS. 2005;9(2):141-147.
    12. Fawcett SL, Stager DR Sr, Felius J. Factors influencing stereoacuity outcomes in adults with acquired strabismus. Am J Ophthalmol. 2004;138(6):931-935.
    13. Fawcett SL, Felius J, Stager DR. Predictive factors underlying the restoration of macular binocular vision in adults with acquired strabismus. J AAPOS. 2004;8(5):439-444.
    14. Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. J AAPOS. 2004;8(5):435-438.
    15. Mills MD, Coats DK, Donahue SP, Wheeler DT; American Academy of Ophthalmology. Strabismus surgery for adults: A report by the American Academy of Ophthalmology. Ophthalmology. 2004;111(6):1255-1262.
    16. Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. Trans Am Ophthalmol Soc. 2003;101:201-207.
    17. Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults--I. Clinical characteristics and treatment. J AAPOS. 2003;7(4):233-240.
    18. Yan J, Zhang H. The surgical management of strabismus with large angle in patients with Graves' ophthalmopathy. Int Ophthalmol. 2008;28(2):75-82.
    19. McCracken MS, del Prado JD, Granet DB, et al. Combined eyelid and strabismus surgery: Examining conventional surgical wisdom. J Pediatr Ophthalmol Strabismus. 2008;45(4):220-224.
    20. Kushner BJ. The efficacy of strabismus surgery in adults: A review for primary care physicians. Postgrad Med J. 2011;87(1026):269-273.
    21. Ghasia F, Brunstrom-Hernandez J, Tychsen L. Repair of strabismus and binocular fusion in children with cerebral palsy: Gross motor function classification scale. Invest Ophthalmol Vis Sci. 2011;52(10):7664-7671.


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