Number: Last Review 06/23/2016 Effective: 09/25/2001 Next Review: 06/22/2017. Review History
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1 1 of 8 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: Last Review 06/23/2016 Effective: 09/25/2001 Next Review: 06/22/ 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. Review History Definitions Aetna considers the use of amniotic membrane in strabismus surgery experimental and investigational because its clinical value has not been established. See CPB 293 Corneal Graft with Amniotic Membrane Transplantation or Limbal Stem Cell Transplantation. Clinical Policy Bulletin Notes Aetna considers repair of strabismus cosmetic when there is no expected improvement of fusion.
2 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 extraocular 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). Use of Amniotic Membrane in Strabismus Surgery: 2 of 8 In a prospective, randomized study, Kirsch et l (2014) evaluated the effect of amniotic membrane in reducing inflammation, fibrosis, adhesion formation, and ocular motility restrictions following strabismus surgery. In the 1st stage, a total of 17
3 3 of 8 rabbits underwent superior rectus muscle recession in both eyes. Surgery was performed in the same manner, but human amniotic membrane was placed over the muscle without sutures in the right eye after recession. After 15 days, the rabbits were killed and their orbits were exenterated and evaluated histopathologically to quantify tissue inflammation and fibrosis. In the 2nd stage, 5 rabbits underwent the same procedure but were killed after 30 days. A dynamometer was used to measure the force required to displace all eyes. At 15 days post operatively, eyes with amniotic membrane exhibited an increased inflammatory response and less fibrosis than eyes without amniotic membrane. At 30 days post operatively, eyes with amniotic membrane continued to exhibit increased inflammation and less fibrosis than eyes without amniotic membrane. In the dynamometer test, more force was needed to displace eyes without amniotic membrane after 15 days, but there was no significant difference between the forces needed at 30 days. The authors concluded that human amniotic membrane in rabbits led to an increase in the inflammatory process and a decrease in fibrosis formation following strabismus surgery. CPT Codes / HCPCS Codes / ICD 10 Codes Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+": ICD 10 codes will become effective as of October 1, 2015: CPT codes covered if selection criteria are met: Strabismus surgery, recession or resection procedure: one horizontal muscle two horizontal muscles one vertical muscle (excluding superior oblique) two or more vertical muscles (excluding superior oblique) Strabismus surgery, any procedure, superior oblique muscle Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for primary procedure)
4 4 of 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) 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) Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure) 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) Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for primary procedure) Release of extensive scar tissue without detaching extraocular muscle (separate procedure Chemodenervation of extraocular muscle ICD 10 codes covered if selection criteria are met: H49.00 H49.9 H50.00 H50.9 Paralytic strabismus Other strabismus ICD 10 codes not covered for indications listed in the CPB: Z41.1 Encounter for cosmetic surgery 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: Gill MK, Drummond GT. Indications and outcomes of strabismus repair in visually mature patients. Can J Ophthalmol. 1997;32(7):
5 5 of 8 3. American Academy of Ophthalmology (AAO). Esotropia and exotropia. Preferred Practice Pattern. San Francisco, CA: AAO; September Way LW, ed. Current Surgical Diagnosis and Treatment. Boston, MA: Appleton & Lange; 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 Available at: /aao/member/policy/adult.cfm. Accessed October 15, Beauchamp CL, Beauchamp GR, Stager DR, et al. The cost utility of strabismus surgery in adults. J AAPOS. 2006;10(5): Hatt SR, Leske DA, Kirgis PA, et al. The effects of strabismus on quality of life in adults. Am J Ophthalmol. 2007;144(5): Beauchamp GR, Felius J, Stager DR, Beauchamp CL. The utility of strabismus in adults. Trans Am Ophthalmol Soc. 2005;103: Jackson S, Harrad RA, Morris M, Rumsey N. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol. 2006;90(7): Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults III. The effects on disability. J AAPOS. 2005;9(5): 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): Fawcett SL, Stager DR Sr, Felius J. Factors influencing stereoacuity outcomes in adults with acquired strabismus. Am J Ophthalmol. 2004;138(6): Fawcett SL, Felius J, Stager DR. Predictive factors underlying the restoration of macular binocular vision in
6 6 of 8 adults with acquired strabismus. J AAPOS. 2004;8(5): Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. J AAPOS. 2004;8(5): 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): Mets MB, Beauchamp C, Haldi BA. Binocularity following surgical correction of strabismus in adults. Trans Am Ophthalmol Soc. 2003;101: Beauchamp GR, Black BC, Coats DK, et al. The management of strabismus in adults I. Clinical characteristics and treatment. J AAPOS. 2003;7(4): Yan J, Zhang H. The surgical management of strabismus with large angle in patients with Graves' ophthalmopathy. Int Ophthalmol. 2008;28(2): 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): Kushner BJ. The efficacy of strabismus surgery in adults: A review for primary care physicians. Postgrad Med J. 2011;87(1026): 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): Dotan G, Nelson LB, Mezad Koursh D, et al. Surgical outcome of strabismus surgery in patients with unilateral vision loss and horizontal strabismus. J Pediatr Ophthalmol Strabismus. 2014;51(5): Kirsch D, Lowen MS, Fialho Cronemberger MF, Sato EH. Amniotic membrane for reducing the formation of adhesions in strabismus surgery: Experimental study in rabbits. J Pediatr Ophthalmol Strabismus. 2014;51(6):
7 7 of Coats DK, Paysse EA. Evaluation and management of strabismus in children. UpToDate Inc., Waltham, MA. Last reviewed April 2016.
8 8 of 8 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. Copyright Aetna Inc.
9 AETNA BETTER HEALTH OF PENNSYLVANIA Amendment to Aetna Clinical Policy Bulletin Number: 0566 Strabismus Repair There are no amendments for Medicaid. Updated 01/2017
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