Pediatric strabismus is a medical condition that affects the eyes of children where the eyes do not gaze in the same direction simultaneously. It’s also known as crossed eyes or squint.

Strabismus is due to a failure of the eyes’ muscle to coordinate together, and in severe cases, it can lead to a permanent decrease in vision due to the brain’s suppression of vision from one of the eyes. The treatment for pediatric strabismus is surgery, and it is normally covered under most medical insurance policies.

However, the type of insurance coverage available for strabismus surgery significantly varies based on the individual’s medical plan.

The Cost of Pediatric Strabismus Surgery

The cost of strabismus surgery varies based on the surgical procedure’s intensity and the doctor performing the surgery.

The cost of strabismus surgery is usually a cause of concern for many parents due to the possibility of needing multiple surgeries to correct the problem. Pediatric strabismus surgeries can cost, on average, between $5,000 to $10,000, which might not be affordable for most families.

Insurance Coverage for Pediatric Strabismus Surgery

Most medical insurance covers strabismus surgery since it’s a medical procedure that helps to improve the child’s medical well-being.

However, when looking into the specific type of insurance coverage, parents should talk to their insurance providers about their policy’s coverage of pediatric eye surgery. Most insurance policies require the child has a medical necessity for surgery.

Medical necessity is established through the doctor’s documentation that surgery can significantly improve the child’s vision or reduces severe symptoms that they may experience from the condition.

Insurance coverages vary and can depend on several factors, such as geographical location and the child’s unique medical needs. When it comes to strabismus surgery, finding a provider within the insurance network is the most optimal choice.

In-network providers’ cost is usually lower, and it can reduce out-of-pocket expenses for the parents. However, in some circumstances, there may not be any in-network providers for pediatric strabismus surgery available, and the parents may have to opt for out-of-network providers.

Types of Insurance Coverage for Pediatric Strabismus Surgery

There are three main types of insurance coverage for pediatric strabismus surgery:.

1. HMO insurance plans

Health Maintenance Organization (HMO) insurance plans usually have a network of doctors and hospitals that the insured can visit to receive health care.

A child with HMO insurance who needs pediatric strabismus surgery will have to use an in-network provider who works with the child’s insurance plan. Parents who opt for HMO’s insurance plan should verify upfront that the insurance plan covers pediatric eye surgery before undergoing any exams or therapy sessions.

2. PPO insurance plans

Preferred Provider Organization (PPO) insurance plans offer in-network and out-of-network benefits.

The insurance plan still shares some costs with the insured even when using an in-network provider, and the insured can use out-of-network providers, although the cost share is usually higher. PPOs plans are an excellent option for parents who may live in geographical areas where the insurance provider’s network is limited.

3. POS insurance plans

Point of Service (POS) insurance plans provide in-network and out-of-network benefits.

The insured can choose either a primary care physician who then provides referrals to specialists in the insurance network or see specialists outside the network but pay a higher cost share. POS insurance plans are suitable for families with children who need pediatric strabismus surgery at a facility outside the insurance network.

When is Surgery Considered Medically Necessary?

Most insurance policies require that the surgery meet medical necessity criteria before considering coverage for pediatric strabismus surgery. Multiple factors can indicate that surgery is necessary, such as:.

1. Reduced Vision

A child’s vision may become impaired due to strabismus. In such cases, pediatric strabismus surgery may be medically necessary, and insurance policies may cover it.

2. Chronic Headaches

When a child has long-term headaches or migraines due to strabismus, a surgeon may determine that the child needs surgical intervention. Insurance policies may cover the cost of strabismus surgery in this case.

3. Double Vision

Double vision is a common occurrence for children with strabismus. In severe cases, the double vision may become permanent.

In such cases, pediatric strabismus surgery is medically necessary, and insurance policies are likely to cover the cost of surgery.

4. Aesthetics

In cases where pediatric strabismus has affected aesthetic appearance, parents may opt for surgery to fix their child’s appearance. In such cases, medical necessity may not be established, and the insurance policy may not cover the cost.

However, some insurance policies cover costs associated with cosmetic concerns as well, and parents may talk to their insurance provider to understand if they are eligible for such coverage.

Conclusion

Pediatric strabismus surgery is often medically necessary and can have a significant impact on a child’s vision and well-being. Insurance coverage for pediatric strabismus surgery varies from one policy to another.

Parents must understand their insurance policy’s network of providers’ coverage, the network’s limitations, and their ability to access in-network providers for pediatric strabismus surgery. Additionally, parents must determine the medical necessity of their child’s surgery, as most insurance policies require documentation proving the medical need for surgery.