67316
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
10.05
Facility
$596.21
Non-Facility
$596.21
Documentation Required
- "Diplopia is documented" — documentation of diplopia is required when applying the adult selection criteria.
- Documentation that there is "an impairment of peripheral vision due to esotropia (marked turning inward of eye)" when that is the basis for surgery.
- Documentation that "restoration of alignment will restore ability to maintain fusion" (clinical assessment/opinion that surgical alignment will permit fusion).
- Age of patient documented (adult 18+ vs child) since the adult medical necessity criteria differ from pediatric indications (policy notes strabismus surgery is medically necessary for children diagnosed with strabismus).
Key Coverage Criteria
- Strabismus surgery is considered medically necessary for children diagnosed with strabismus.
- CPT codes covered if selection criteria are met: 67311, 67312, 67314, 67316, 67318, +67320, +67331, +67332, +67334, +67335, +67340, 67343, 67345 (as listed in the CPB).
- ICD-10 codes covered if selection criteria are met: H49.00 - H49.9 (Paralytic strabismus); H50.00 - H50.9 (Other strabismus); H53.10 (Unspecified subjective visual disturbances [visual confusion]); H53.2 (Diplopia [double vision]); H53.30 - H53.34 (Other and unspecified disorders of binocular vision [Loss of binocular vision or fusion]); H53.8 (Other visual disturbances [visual confusion]).
- 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.
- Strabismus surgery is considered medically necessary for children diagnosed with strabismus.
- Covered ICD-10 diagnoses when selection criteria are met: H49.00 - H49.9 (Paralytic strabismus).
2 Active Policies
AETNA-CPB-0566 — Strabismus Repair
ANTHEM-CG-SURG-41 — CG-SURG-41 Surgical Strabismus Correction
Related Codes
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