CommercialCoverageMedium impact
Strabismus Repair (CPB 0566, reviewed 2026-08-06)
Aetna·Ophthalmology·Medical Policy
Effective date
Aug 6, 2026
We identified it
Aug 17, 2026
Summary
Aetna's strabismus repair policy (CPB 0566, effective 2026-08-06) clarifies coverage for surgical repairs in adults and children, establishes specific medical necessity criteria for adults, and designates amniotic membrane use and Ologen implants as experimental/investigational (non-covered). Billing teams must ensure claims include appropriate ICD-10 diagnosis codes reflecting covered indications and avoid billing for non-covered materials.
Action Required
By August 6, 2026: (1) Billing team must update claim submission rules to require one of the following ICD-10 diagnosis codes for covered strabismus repair claims: H53.2 (diplopia), H49.00-H49.9 (paralytic strabismus), H50.00-H50.9 (other strabismus), or H53.30-H53.34 (loss of binocular vision/fusion). Claims with diagnosis code Z41.1 (cosmetic surgery) will be denied. (2) Configure billing system to REJECT claims containing CPT codes 65778, 65779, or 65780 (amniotic membrane placement) or any claim referencing Ologen biodegradable collagen matrix implant—these are non-covered experimental procedures. (3) For adult patients (18+), ensure provider documentation supports one of the four covered indications (diplopia, esotropia with peripheral vision impairment, loss of fusion, or visual confusion). (4) For pediatric strabismus cases, no specific indication documentation is required beyond diagnosis code. (5) Update internal billing guidelines and provider education materials to reflect that amniotic membrane and Ologen use will result in claim denials. Failure to implement these edits will result in denials and unnecessary rework.