Orlando Harmon
Strabismus, or squint eye, is a medical condition that causes the eyes to become misaligned. This can cause a variety of issues, including blurry vision, double vision, poor depth perception, lazy eye, eye fatigue, and headaches. While surgery is the most effective treatment for strabismus, it can be costly, and many patients are unsure whether their medical insurance will cover the procedure.
| Characteristics | Values |
|---|---|
| What is strabismus? | An eye condition in which the eyes are misaligned, also known as a squint or lazy eye. |
| What is strabismus surgery? | A procedure to correct strabismus by obtaining normal visual acuity in each eye, improving fusion, eliminating associated sensory adaptations or diplopia, and improving visual fields. |
| Is strabismus surgery covered by insurance? | Most health insurance providers cover strabismus surgery as it is considered medically necessary and can impact quality of life. However, some insurance policies have restrictions and limitations, so it is best to check with your insurance company. |
| Factors affecting insurance coverage | The level of severity, whether the surgeon is in or out of your insurance network, hospital location, presurgical and aftercare, anesthesia or sedation, additional medical personnel, and surgeon fees. |
| Exclusions from insurance coverage | Post-surgery medications and eye drops, post-op therapy, diagnostic tests and evaluations, and prescription glasses. |
| Cost of strabismus surgery without insurance | $4000-$20,000, depending on various factors. |
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What You'll Learn
Strabismus surgery is considered cosmetic and may not be covered by insurance
While strabismus surgery is rarely considered purely cosmetic, some insurance companies may deem it as such. This is because strabismus is often believed to be a cosmetic issue, and patients may feel vain for seeking treatment. However, strabismus is a medical condition that causes functional disability, hinders eye contact, and affects eye function, which can negatively impact a person's quality of life and mental health.
Strabismus is an eye condition in which the eyes are misaligned, causing problems with eye function and depth perception. It can also result in double vision, making tasks such as driving difficult. The goal of strabismus surgery is to obtain normal visual acuity in each eye, improve fusion, and eliminate any associated sensory adaptations or diplopia. The surgery involves weakening or strengthening the extra-ocular muscles by making a small incision in the conjunctiva, the outer covering of the sclera of the eye.
If strabismus surgery is considered cosmetic by an insurance company, it may not be covered by insurance. This means that patients will have to pay out of pocket for the procedure, which can be costly. In some cases, the surgery may cost over $20,000, including anesthesia. However, even if insurance does not cover the surgery, there may be other options for reducing fees, such as negotiating with the facility or choosing a plan with a low out-of-pocket maximum.
To ensure that strabismus surgery is covered by insurance, patients can ask their ophthalmologist to pre-approve the procedure with their insurance carrier. Additionally, doctors can use a specific billing code to indicate that the surgery is medically necessary, which may increase the likelihood of insurance coverage. By coding the surgery as "necessary," patients may be able to have a significant portion of the costs covered by their insurance plan.
It is important to note that the cost of strabismus surgery can vary depending on several factors, including the severity of the condition, hospital location, and whether the surgeon is in or out of the insurance network. Patients should carefully review their insurance plans and consult with their healthcare providers to understand their coverage and any potential out-of-pocket expenses.
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Some insurance policies cover the surgery as a medical necessity
While strabismus surgery is often considered cosmetic and therefore not covered by insurance, some insurance policies do cover the procedure as a medical necessity. Strabismus, or "squint eye", is a condition in which the eyes are misaligned, which can cause blurry vision, double vision, poor depth perception, lazy eye (amblyopia), eye fatigue, and headaches. 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.
Most insurance companies cover this surgical procedure because it corrects a medical condition that causes functional disability. For instance, misaligned eyes can cause blurry vision, double vision, poor depth perception, lazy eye (amblyopia), eye fatigue, and headaches. However, some insurance policies have restrictions—for instance, on who may perform your surgery and what will be covered—and other limitations. Therefore, it is important to check with your insurance company to see if you need to choose an in-network provider or anticipate out-of-pocket costs.
To confirm that the surgery is medically necessary and get it covered by health insurance, certain criteria need to be met. These criteria include the documentation of diplopia or double vision in the patient and the severe impairment of the patient's peripheral vision due to esotropia. If these criteria are met, the surgery is considered reconstructive (not cosmetic), and the patient can get the treatment cost covered by health insurance. If the patient doesn't meet the criteria, the insurance company has the right to deny the claim request to cover the treatment expense.
In addition to health insurance, some expenses associated with strabismus surgery may be covered by vision care plans. For example, ophthalmologists often recommend vision therapy for patients before or after strabismus surgery to improve brain-eye coordination. However, in most cases, vision therapy is excluded, meaning that the insurance company will not cover the expenses. It is important to carefully review the terms and conditions of your insurance policy to understand what expenses are covered and what expenses are excluded.
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The cost of strabismus surgery without insurance is high
The cost of strabismus surgery without insurance is indeed high. The cost of the surgery depends on several factors, including the severity of the condition, the hospital location, and the surgeon's fees. On average, strabismus surgery costs between $5,000 and $10,000 without insurance. In some cases, the cost can be as low as $3,943 or as high as $20,000.
Strabismus surgery is typically considered medically necessary rather than cosmetic. It is a procedure that corrects misaligned eyes, allowing them to become properly aligned. This condition is often referred to as "lazy eye" or "wandering eye," where the eyes appear to look in different directions. It is caused by an imbalance or weakness in the muscles that position the eyes, preventing them from working together.
Most insurance companies cover strabismus surgery because it is considered a medical condition that impacts an individual's quality of life and can cause functional disabilities. However, without insurance, the out-of-pocket costs for this procedure can be significantly higher. In addition to the surgery itself, there are other costs to consider, such as anesthesia or sedation, presurgical care, aftercare, and prescription eye drops. These additional costs can quickly add up, making the overall expense of strabismus surgery without insurance coverage extremely high.
It is worth noting that not everyone with strabismus will require surgery. In some cases, non-surgical treatments such as eye exercises and prescription eyewear can be effective. These non-surgical options are often the first course of treatment and can help save money on overall treatment costs.
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The surgery is performed under anaesthesia
The decision to cover the costs of strabismus surgery varies across insurance companies. While some companies may deem the surgery cosmetic and therefore not cover it, others acknowledge the condition as a medical issue that negatively impacts the quality of life and covers the costs. In the latter case, patients can expect to pay between $1,000 and $2,000 out of pocket after deductibles. However, it is worth noting that even with insurance coverage for the surgery itself, patients may still receive a separate "surprise" bill for the anaesthesia, which they might have to negotiate payment for with their insurance company.
Strabismus surgery is usually performed under anaesthesia, with the type of anaesthesia depending on the patient's age and the specific procedure being carried out. In children, strabismus surgery is one of the most common eye operations and is typically performed under general anaesthesia. Children who undergo this procedure are usually completely sedated, and prophylactic antiemesis with ondansetron and dexamethasone is often recommended to prevent postoperative nausea and vomiting.
For adults, the type of anaesthesia used depends on the specific procedure being carried out. Some adult patients may prefer to be awake during the procedure, in which case local anaesthesia can be administered. However, other adult procedures may require general anaesthesia as well. Topical anaesthesia, for example, is used in pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery, and some adjustable suture strabismus surgery. However, its use is limited to cooperative adult patients.
In both children and adults, the surgery involves making an incision over the white part of the eye and then separating and reattaching the muscle of interest with tiny sutures in a different position. This changes the angle of the eye and allows for proper alignment.
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Vision therapy is not covered by most insurance plans
While strabismus surgery is deemed medically necessary, it is often considered cosmetic surgery by insurance companies. This is because the eyes are misaligned, and the surgery is required to make them appear more aligned. However, in reality, strabismus surgery is a reconstructive medical intervention that impacts a person's quality of life and mental health. It is also known to cause functional disability, hindering eye contact and causing problems with depth perception and side vision.
Vision therapy, on the other hand, is not covered by most insurance plans. This is primarily due to misconceptions about its efficacy, limited recognition, and cost considerations. Vision therapy is often misunderstood as an elective or non-essential treatment rather than a legitimate medical intervention. It is a specialized form of therapy that aims to improve visual skills and processing and is known to be effective in addressing various vision-related issues, including lazy eye, eye turn (strabismus), and difficulties related to reading and learning. However, it often requires multiple sessions over an extended period, which can be costly for patients and insurance companies.
The lack of recognition within the medical community also contributes to the lack of insurance coverage for vision therapy. It is still considered a relatively niche treatment compared to more traditional forms of therapy or medical treatments. As a result, insurance companies may not view it as essential and may exclude it from coverage policies to mitigate expenses.
In some cases, insurance plans may offer partial coverage for vision therapy under certain circumstances. Additionally, patients can explore flexible spending accounts (FSAs) or health savings accounts (HSAs) to help cover expenses. Some vision therapy providers also offer financing options or payment plans to make treatment more accessible.
It is important to carefully review insurance policies, as coverage for vision therapy can vary. Even if a patient finds a provider that accepts their insurance, their specific policy may not cover vision therapy due to negotiations made by their employer to obtain a lower rate.
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Frequently asked questions
No, strabismus surgery is considered a medical necessity for most patients. Delayed treatment of the condition can significantly impair the patient's vision and brain-eye coordination, leading to other issues. However, some insurance companies may still consider it cosmetic.
The cost of strabismus surgery depends on several factors, including the severity of the condition, the surgeon's fees, hospital location, and whether or not your insurance will cover all or part of the procedure.
The cost of strabismus surgery without insurance can vary. Some people have reported costs of over $20,000, while others have reported costs of around $4,000 for the surgery and $3,000 for hospital services.
