Aetna announced this week that it will no longer require preauthorization for cataract surgeries starting July 1, 2022, except for people enrolled in Medicare Advantage in Florida and Georgia.* The move comes after a year of intense opposition and advocacy from physicians, administrators, and ophthalmic societies.

"After operating under this policy for 1 year and accumulating real-time data on these surgeries, we have decided to discontinue our national precertification policy effective July 1, 2022. Going forward, we will focus on retrospective reviews of procedures and providers where questions of medical necessity exist," Aetna said in a statement to Eyewire News. "We regularly evaluate and update our clinical policies and processes to help ensure our members are provided with the best care. This decision supports that practice."

On July 1, 2021, Aetna made changes to its national precertification list for several procedures,[1] the most common of which was cataract surgery. The policy required preauthorization a minimum of 2 weeks before a cataract procedure is performed for Aetna members. The decision, which opponents say was made swiftly and without consideration of safety concerns, drove the leadership of the AAO and the ASCRS to release statements voicing their opposition.[2,3]

“Put very simply, we think it’s unnecessary, disruptive, and burdensome,” David Glasser, MD, AAO secretary for federal affairs, said in an interview with BMC Vision.[4] “Burdensome for patients, their families, and physicians; unnecessary because we don’t think that the issue of unnecessary cataract surgery is as large as Aetna thinks it is. And we don’t think that this method is an efficient or effective way of trying to reduce unnecessary cataract surgery—although we share Aetna’s goal of reducing or eliminating unnecessary surgery.”

Preauthorizations, often referred to as prior authorizations, give health insurance companies a chance to review how necessary a certain procedure or medication may be in treating a condition. Preauthorization has a valid role in the health care process as a way to ensure that a service or drug is truly medically necessary. Opponents of the Aetna policy, however, say the decision to include cataract surgery was primarily a financial decision.

ASCRS and AAO held several meetings with Aetna leadership, questioning the policy’s necessity, detailing the difficulties with rollout and issues with compliance. Details of those discussions can be found on the July 7, 2021 episode of EyewireTV.

The Academy estimates that 10,000 to 20,000 Aetna beneficiaries had their cataract surgery unnecessarily delayed in the month of July 2021 alone. Since then, the Academy has heard “countless stories” of patients who were delayed or denied sight-restoring care.

“Aetna’s decision to impose a prior authorization requirement for cataract surgery was very difficult to understand since the indications for surgery are well established and the benefits clear,” Stephen D. McLeod, MD, CEO of the Academy, said in an AAO news release. “And the immediate impact on patients subject to unnecessary delay should have been obvious: this is an incredibly common procedure with some 4 million Americans undergoing cataract surgery each year. It has an extremely high success rate with regards to safety and vision improvement, and studies have consistently shown that cataract surgery improves quality of life, lowers the risk of falls and car accidents, and is associated with reduced cognitive decline amongst older adults.”

The Academy teamed up with the ASCRS to provide documented patient cases and membership data that substantiated the need for Aetna to rescind its policy.

“As president of ASCRS, I'm thrilled about the work that was done over the past year by ASCRS and AAO that led to Aetna dropping its prior authorization policy for cataract surgery. As Richard Hoffman, MD, said last year, 'the best two people qualified to determine if cataract surgery is necessary are the patient and their ophthalmologist.' I could not agree more and am pleased that right has been restored,” ASCRS President Douglas Rhee, MD, said in a news release.

Advocacy efforts included meeting with the Centers for Medicare & Medicaid Services (CMS) to request increased oversight and working with bipartisan Congressional leaders to advance the Improving Seniors’ Timely Access to Care Act of 2021 (H.R. 3173/S. 3018).

Today, support for this legislation, which aims to put guardrails around prior authorization, has grown to include more than 300 U.S. House members and 34 U.S. Senators, according to AAO. The legislation has been endorsed by nearly 500 patient, provider, and other advocacy organizations.

If enacted, the legislation would require Medicare Advantage plans to:

• Establish an electronic prior authorization (ePA) program and require MA plans to adopt ePA capabilities, including the ability to provide real-time decisions;
• Annually publish specified prior authorization information, including average response time and the percentage of requests approved, to improve transparency;
• Ensure prior authorization requests are reviewed by qualified medical personnel; and
• Protect beneficiaries from any disruptions in care due to prior authorization requirements as they transition between MA plans.

*Cataract surgery for Florida and Georgia MA beneficiaries will still require prior authorization through iCare.

References

1. Changes to our National Precertification List (NPL). Aetna. Accessed July 7, 2021. https://www.aetna.com/health-care-professionals/newsletters-news/office-link-updates-march-2021/90-day-notices-march-2021/changes-to-our-national-precertification-list.html

2. Statement: American Academy of Ophthalmology and ASCRS urge Aetna to reverse disruptive new policy on cataract surgery. AAO. July 1, 2021. Accessed July 5, 2021. www.aao.org/newsroom/news-releases/detail/aetna-urged-to-reverse-policy-on-cataract-surgery

3. Insurance company policy delays sight-restoring surgery, puts patients in jeopardy. ASCRS. July 1, 2021. Accessed July 5, 2021. https://ascrs.org/news/ascrs-news/ascrs-press-release-regarding-prior-authorization-policy

4. Daily S. Aetna Policy Draws Sharp Criticism From Eye Care Groups and Administrators. CRST. August, 2021. https://crstoday.com/articles/2021-aug/aetna-policy-draws-sharp-criticism-from-eye-care-groups-and-administrators/.