Dealing With Peer-to-Peer Authorizations

HOT TOPIC

First-Line POAG Treatment Preferences Revealed

A new survey released in the Journal of Glaucoma highlights that, for first-line treatment of patients with primary open-angle glaucoma (POAG), laser trabeculoplasty is more likely to be preferred over topical drops by US physicians who are relatively new in practice, have a larger glaucoma patient base, and who perform more microinvasive glaucoma surgery (MIGS).

The survey was conducted to assess the practice patterns of ophthalmologists in the initial treatment and management of glaucoma. The researchers thought that practice patterns may be changing due to the new options available for treating POAG. The survey was conducted by performing a retrospective claim analysis of data from 2007 to 2014 that analyzed patients whose first diagnosis of POAG was made in 2010.

To characterize primary glaucoma treatment preferences (topical medications vs selective laser trabeculoplasty [SLT] vs sustained-release implants), a 33-question survey was sent to an American Society of Cataract and Refractive Surgery database. Out of 19,246 surveys sent, 252 were returned (a 1.3% return rate).

The survey showed that 73.6% of surveyed doctors used topical medications as first-line treatment for POAG, while 26.4% started with SLT. It was found that the more recent completion of an ophthalmology residency or the greater implementation of MIGS procedures increased the respondent’s likelihood of using SLT. “It was also observed that the majority of either group, laser or topical drops first, preferred a trabecular meshwork bypass stent in cases of moderate POAG and visually significant cataract … The results of this survey demonstrate a continuing unmet need to educate our colleagues on evidence-based treatment results for POAG,” the researchers stated.

My Two Cents

It should come as no surprise to any of you reading this newsletter that I am very much in support of the last statement regarding MIGS procedures. If you’re referring your patients with cataracts who also have glaucoma to a cataract surgeon who does not perform MIGS procedures, you are doing your patients a disservice. However, back to the study profiled—as additional states allow optometrists to perform SLT and the technological advances for that procedure continue to develop, such as the Eagle device from Belkin Vision, I would expect surgical treatments to be selected more often as first-line options for a larger number of patients. The studies show that this is in our patients’ best interest!

OUTSIDE THE LANE

Robot-Delivered AMD Treatment Reduces Injections and Cuts Costs

In a new study, researchers from King’s College London successfully employed a custom-built robot to treat wet age-related macular degeneration (AMD). This innovative approach involving robotic radiotherapy functions by aiming three beams of highly focused radiation into the diseased eye. According to the researchers, the method “offers precise targeting of treatment to the eye, improving patient outcomes and reducing costs.”

The trial, published in The Lancet, found that patients with wet neovascular AMD treated with the custom-built robot, which administered a one-off, minimally invasive dose of radiation, followed by the patient’s normal treatment with injections, needed fewer injections. The researchers estimate that this method could potentially save around 1.8 million injections per year around the world. They also found that it saved England’s health care system 565 pounds for each patient over the first 2 years. (Read more here.)

My Two Cents

It’s not all about money, obviously; however, this new, extremely precise radiation treatment shows all sorts of promise for our patients with wet AMD. Personally, I can’t believe all of the innovation that seems to be coming out in the AMD world. Between new drugs for geographic atrophy (I’m looking at you, Syfovre [Apellis] and Izervay [Astellas]) and the constant refinement of anti-VEGF therapies, we seem to be entering a golden age of AMD treatment.

CAN YOU RELATE

Peer-to-peer prior authorization/medical review. If you hear these words in optometry, it’s safe to assume you and your patient have been through the wringer, courtesy of their “insurance” company. This past week, we received a denial from a vision plan stating that a patient’s topography (see below) was normal and that glasses were an appropriate solution for them.

First off, the patient’s topography was not normal. (Not pictured is the large posterior floater upon tomography testing that shows corneal ectasia.) “There is no eye doctor in this world that would call this topography normal,” I thought to myself, as my blood began to boil, not only because they were basically telling me that I was wrong, but also because I thought they were denying this patient the ability to see clearly and enjoy a full life, as glasses would not provide her with vision to allow her to legally drive. Another important fact to note: This patient’s vision plan approved the scleral lenses I submitted as my recommended treatment the last two times we filed for them the past 5+ years.

So, I set things in motion to remedy this situation. Not only did my patient call her “vision insurance” numerous times, only to sit on hold for hours and then get hung up on/disconnected, but so did my staff. Finally, I was able to schedule a peer-to-peer meeting. When our 12:30 pm call took place (they called me more than 10 minutes late and I was tempted to keep them on hold for 4-6 hours to give them a taste of their own medicine), I was introduced to the two doctors reviewing the case. Having done this before, the first thing I always do is ask the doctors for their background, specialty, and where they practice. One of the doctors on the call assigned to approving this patient’s scleral lens application was a retina specialist. Let me repeat that for the speed readers: This vision plan chose one of their employed retina specialists to assess whether my patient needs scleral lenses.

As my editor Karen Roman can probably attest, I’m a pretty even-keel guy, and it takes quite a bit to rattle me; however, I lost it on these two vision plan-employed doctors. After I blew a gasket, they assured me they were qualified to assess the case. I asked them to repeat why my patient’s lenses were denied. They again noted that the topography appeared “normal” and showed no signs of corneal ectasia. I sighed and asked the retina specialist to please define corneal ectasia. Then I asked the other doctor, who admirably tried to provide her own answer, but I interrupted her to remind her that there isn’t a formal definition of corneal ectasia (true story, look it up!). I also went on a tirade about the topography readings and asked if either of them had ever had an eye exam.

Long story short: there are people who have no business reviewing our patients’ charts and making decisions that affect their everyday lives. Be an advocate for these patients. Learn to sniff out the BS and see past the smoke screens these “insurance” plans put out. Also, it’s okay to lose your cool sometimes. Just be sure to apologize and make friends when it’s all done and they’ll agree to pay for your patient’s lenses!

IMAGE OF THE WEEK

White traumatic cataract.

Paul Hammond, OD, FAAO, @kmkoptometrypro

QUOTE OF THE WEEK

“To be successful at anything, the truth is you don’t have to be special. You just have to be what most people aren’t: consistent, determined, and willing to work for it.”

— The G.O.A.T. and Michigan man, Tom Brady, former NFL football player