Aetna considers strabismus repair medically necessary for adults 18 years of age or older only if both of the following criteria are met:
Diplopia is documented, or there is an impairment of peripheral vision due to esotropia (marked turning inward of eye); and
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.
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:
ICD-9 codes covered if selection criteria are met:
190.0 - 190.9
Malignant neoplasm of eye
191.0 - 191.9
Malignant neoplasm of brain
Secondary malignant neoplasm of brain and spinal cord
Secondary malignant neoplasm of other parts of nervous system
224.0 - 224.9
Benign neoplasm of eye
225.0 - 225.2
Benign neoplasm of brain, cranial nerves, or cerebral meninges
Carcinoma in situ of eye
242.00 - 242.91
Thyrotoxicosis with or without goiter
Other visual distortions and entoptic phenomena
376.21 - 376.22
Nutritional optic neuropathy
Toxic optic neuropathy
Ischemic optic neuropathy
Other disorders of optic nerve
378.51 - 378.52
Paralytic strabismus, third or oculomotor nerve palsy, partial or total
Paralytic strabismus, sixth or abducens nerve palsy
430 - 438.9
800.00 - 804.99
Fracture of skull
850.00 - 854.19
Intracranial injury, excluding those with skull fracture
871.0 - 871.6
Open wound of eyeball
Late effect of fracture of skull and face bones
Late effect of open wound of head, neck, and trunk
Late effect of contusion
Late effect of intracranial injury without mention of skull fracture
Late effect of injury to cranial nerve
921.3 - 921.9
Contusion of eye
Head injury, unspecified
Personal history of injury
ICD-9 codes not covered for indications listed in the CPB:
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:
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.
Gill MK, Drummond GT. Indications and outcomes of strabismus repair in visually mature patients. Can J Ophthalmol. 1997;32(7):436-440.
American Academy of Ophthalmology (AAO). Esotropia and exotropia. Preferred Practice Pattern. San Francisco, CA: AAO; September 2002.
Way LW, ed. Current Surgical Diagnosis and Treatment. Boston, MA: Appleton & Lange; 1994.
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.
Beauchamp CL, Beauchamp GR, Stager DR, et al. The cost utility of strabismus surgery in adults. J AAPOS. 2006;10(5): 394-399.
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.
Beauchamp GR, Felius J, Stager DR, Beauchamp CL. The utility of strabismus in adults. Trans Am Ophthalmol Soc. 2005;103:164-172.
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.
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.
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.
Fawcett SL, Stager DR Sr, Felius J. Factors influencing stereoacuity outcomes in adults with acquired strabismus. Am J Ophthalmol. 2004;138(6):931-935.
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.
Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. J AAPOS. 2004;8(5):435-438.
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.
Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. Trans Am Ophthalmol Soc. 2003;101:201-207.
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.
Yan J, Zhang H. The surgical management of strabismus with large angle in patients with Graves' ophthalmopathy. Int Ophthalmol. 2008;28(2):75-82.
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.
Kushner BJ. The efficacy of strabismus surgery in adults: A review for primary care physicians. Postgrad Med J. 2011;87(1026):269-273.
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.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.