Strabismus: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the corneal collagen cross-linking. Keratoconus is caused by a structural abnormality in the collagen of the cornea, wherein the cornea becomes progressively misshapen over time. Eventually, this may develop into failure of the cornea, with intractable edema and permanent loss of vision. The classic treatment for keratoconus-induced visual decline is a corneal transplant, which places patients at risk for significant complications. Corneal collagen cross-linking has been studied extensively and is now considered part of the standard of care for patients with progressing keratoconus. As compared to a corneal transplant, corneal collagen cross-linking has little to no risk.

The patient’s parent has requested authorization and coverage for 36 vision therapy sessions. The American Optometric Association (AOA) states that, “studies suggest that vision therapy is effective in altering accommodation, with a resultant change in amplitude and facility and a decrease in symptoms.” Studies have demonstrated that vergence therapy improves vergence ability, and that the effects persist over time. Saccadic training has been shown to help with early reading fluency and is an effective treatment over a period of six weeks. The AOA clinical practice guideline supports treatment with up to 20 visits. This patient was diagnosed with general binocular dysfunction, oculomotor dysfunction of pursuits and saccades, and accommodative dysfunction. The patient’s results on the Eye Optics Optometry Center supports an indication for the requested vision therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with an appropriately qualified provider who specializes in ocular facial revision surgery. The records provided for review do not support an indication for the requested consultation with an appropriately qualified provider who specializes in ocular facial revision surgery. With regard to the patient’s lipoma, examination was reportedly normal by two providers without concern for pathology or lipoma. One provider noted that the patient experiences pain with lesions and also outside of the individual lesions. The provider charted that the patient has whole body pain and pain sensitivity that may benefit from evaluation with pain management.

Findings: The physician reviewer found that The patient has requested authorization and coverage for bilateral ptosis surgery. Ptosis surgery is indicated when there is visual compromise due to ptotic upper eyelids. Marginal reflex distance 1 (MRD 1) is the distance between the upper lid margin and the corneal light reflex. Measurable preoperative indicators for medically indicated ptosis surgery include MRD 1 of less than 2 mm and/or impairment of superior vision of 12 degrees or 24%. The records provided for review indicate that the patient’s MRD 1 was measured at 2-3 mm in both eyes on 11/7/22 and 1/11/23, which is consistent with a diagnosis of mild ptosis. There is a lack of documentation indicating impairment of superior vision of 12 degrees or 24%.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for strabismus was denied, the published record says the denial is worth fighting.