Aetna reverses policy requiring pre-approval for cataract surgery
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Starting July 1, Aetna will no longer require pre-approval for cataract surgery except for patients in Florida and Georgia who are enrolled in Medicare Advantage, according to a press release from the American Academy of Ophthalmology.
The announcement comes after Aetna implemented a policy that required pre-approval for all physician-prescribed cataract surgeries in July 2021. According to the release, an estimated 10,000 to 20,000 cataract surgeries among Aetna beneficiaries were delayed in July due to the policy.
“Aetna’s decision to impose a prior authorization requirement for cataract surgery was difficult to understand since the indications for surgery are well established and the benefits clear,” Stephen D. McLeod, MD, CEO of the AAO, said in the 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 regard 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.”
It is still unclear why Medicare Advantage beneficiaries in Florida and Georgia are excluded from the policy reversal, according to the release.
Perspective
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Alice T. Epitropoulos, MD, FACS
The ophthalmology community, through the leadership of the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery, mobilized efforts to educate policymakers and the media about the impact of Aetna’s overreaching mandate requiring prior authorization for all cataract surgeries regardless of patient status and physician medical decision-making.
An overwhelming response from physicians reporting the detrimental impact on patient care and their own office administrative burdens allowed us to convey these first-hand experiences that underscored the illogical and harmful policy put forth by Aetna. The facts were on our side, plain and simple.
Prior authorization can be a reasonable utilization tool in some instances, but when insurers start applying it to safe, common and highly effective procedures such as cataract surgery, with no clinical rationale for the excessive administrative burden and care delays, it becomes something quite dangerous to patient health and well being.
While the ophthalmology community appreciates this outcome, we have spent a year fighting back against Aetna’s policy. A high percentage of cataract surgeries were eventually approved, but Aetna’s ultimate intention remains inexplicable.
What patients, policymakers, journalists and the medical community should learn from this experience is that honest, factual, organized advocacy sometimes actually works. This victory belongs to patients.
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