Aetna Cataract Prior Authorization Update
We have heard from many OOS members regarding Aetna’s new policy requiring prior authorization for cataract surgery (starting July 1). This is a national decision made by Aetna as the American Academy of Ophthalmology (AAO) reported last Friday evening. After intense push back from the Academy and others, the company wasn’t willing to revise its policy. (See the full report from the AAO below.)
In Ohio, the OOS is also advocating against this policy. The physician leadership of the OOS has requested a meeting with Aetna’s Ohio medical director. Additionally, the OOS is reaching out to regulators and the Ohio Department of Medicaid as Aetna covers dual eligible patients in Ohio, now and Medicaid patients starting January 1.
In addition to these efforts, the OOS is also reaching out to Senators Brown and Portman and the Ohio congressional delegation to express our concern for Medicare recipients in Ohio, as Aetna has a Medicare Advantage plan.
This decision by Aetna is basically just bad for patients and practices. It will do nothing but add an administrative burden to the system and jeopardize good patient care. The OOS leadership and staff will continue to advocate for members on this issue and will provide any updates as we have them. If you have any questions, please contact us at firstname.lastname@example.org.
American Academy of Ophthalmology Communication
Aetna Refuses to Budge on Cataract Prior Authorization
Aetna said today that despite strong opposition from the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery, it will require prior authorization for all cataract surgery procedures starting July 1.
Aetna officials, who announced this decision in a meeting with the two organizations, failed to provide concrete reasoning on why this policy is being implemented. Stating only that its internal data showed a less-than-5% variation in medically necessary surgeries, Aetna neither gave actual examples nor presented any rationale for subjecting all cases to precertification.
The Academy and ASCRS will take further actions to get the policy rescinded and ensure patients’ access to medically necessary cataract surgery is not delayed or denied. We are disappointed with Aetna’s response; this policy puts patients at risk of losing vision and increases burdens on practices to an unacceptable level.
“It is very troubling that Aetna, without presenting any evidence that unnecessary cataract surgery is widespread, has chosen to make it more difficult for each and every one of their beneficiaries to obtain this sight-restoring surgery,” said David B. Glasser, MD, Academy secretary for federal affairs. “Not only has the carrier failed to demonstrate sufficient need for this precertification program, but it has also been implemented in such an inefficient manner that we estimate that 10,000 to 20,000 Aetna patients will have their cataract surgery unnecessarily delayed in the month of July alone.”
In addition to requesting clarification on the reasoning and scope of the policy, we raised transparency concerns, as no policy documents had been published and no prior education took place. We discussed concerns from our members on inconsistent instructions from Aetna staff and denials that practices already had received. We requested Aetna immediately withdraw the program to ensure patients receive access to timely cataract treatment.
Aetna not only declined to withdraw the program but refused to pause it. They also failed to address our concerns on the operational aspects of the program and offered no relief for the short implementation timeline, its inoperable portal and unhelpful general support line that has resulted in complete confusion for members.
The immediate negative outcomes for patients are unacceptable.
“Just because cataract surgery is scheduled a few weeks from the time that the decision for surgery is made doesn’t really make it elective in the eyes of the patient,” Dr. Glasser said. “Visual impairment due to cataract is real. Cataracts reduce our patients’ quality of life, interfere with their work and put them at increased risk for falls and automobile accidents."
Here’s what you need to know:
- The policy is effective July 1.
- The policy requires preapproval for all cataract surgeries: CPT codes 66982, 66984, 66987 and 66988.
- This applies for all sites of service and in all markets.
- Precertification requests should be submitted at least two weeks in advance.
- Requests can be submitted through Availity using the “Authorization (Precertification) Add” transaction or you can call 1-866-752-7021 for “guided” Aetna support.
- For Florida and Georgia Medicare-only patients, use the telephone numbers below:
- Florida Medicare only (MEHMO and MEPOS), contact iCare at 1-855-373-7627
- Georgia Medicare only (MEHMO and MEPPO), contact iCare at 1-844-210-7444
What you can do:
If you have experienced any issues with getting approval, contact us at email@example.com.
Contact Aetna directly to express your opposition to this policy. Providers can call Aetna’s Availity support line at 1-866-752-7021.
Support the Academy’s broader efforts to reduce prior authorization’s burdens.