Anthem Blue Cross Connecticut CG-SURG-41 Surgical Strabismus Correction Form

This document addresses strabismus, which refers to eyes that are not properly aligned. Examples of strabismus include one or both eyes that are intermittently or constantly turned in towards the nose (esotropia) or out (exotropia). Strabismus surgery involves surgical weakening or strengthening of the ocular muscles to correct the ocular alignment. The goals of strabismus surgery are to restore or reconstruct normal ocular alignment, obtain normal visual acuity in each eye, obtain or improve fusion, eliminate any associated sensory adaptations or diplopia, and to improve visual fields.

Note: The use of botulinum toxin is not addressed in this document.

Clinical Indications

Medically Necessary:

Adults
Surgical strabismus correction for individuals 18 years of age or older is considered medically necessary for any of the following:

1. Diplopia; or
2. Visual confusion; or
3. Restoration of binocular vision; or
4. Intolerance of prism glasses or patch; or
5. Restoration of visual field in individuals with esotropia; or
6. Elimination or improvement of abnormal head posture; or
7. Improvement of psychosocial function or vocational status.

Pediatrics
Surgical strabismus correction in individuals less than 18 years of age is considered medically necessary for any of the following:

1. Infantile esotropia (inward deviation) with onset before 6 months of age; or
2. Acquired non-accommodative esotropia; or
3. Partially accommodative esotropia; or
4. Any deviation due to neural dysfunction, or threatening normal binocular vision; or
5. Intermittent exotropia (outward deviation); or
6. Constant exotropia; or
7. Hyper/hypotropia (vertical deviation); or
8. Accommodative esotropia that does NOT improve with 3-6 months of refractive correction, patching or when it threatens normal binocular vision.

Not Medically Necessary:

Surgical strabismus correction is considered not medically necessary when the criteria listed above are not met and for all other indications.