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  • Comprehensive Ophthalmology, Pediatric Ophth/Strabismus, Uveitis

    Tumor necrosis factor inhibitors (TNFis) are increasingly being used to treat juvenile idiopathic arthritis (JIA), but delays in treatment authorization could lead to negative effects.

    Study design

    This cohort-based study from Boston Children's Hospital examined delays related to prior authorization (PA) requests for initiation of TNFi therapy in children and young adults aged ≤21 years with a diagnosis of JIA. Public and private insurance outcomes were compared using multiple statistical methods.


    Fifty-four children were prescribed TNFi therapy for JIA, 49 of whom were already on a steroid-sparing agent. Prior authorization for TNFis was required for 53 (98%) insurance plans; 14 PA requests (26%) were denied and required written appeal or peer-to-peer review. Median time of delay was 3 days, but 22% of patients experienced delays of ≥2 weeks. When peer-to-peer approval was required, the median approval time was 15.5 days, compared with 4.8 days without a written appeal or peer-to-peer requirement.


    The limitations of this study include the small sample size and that all patients were treated at a single large academic children's hospital, so the results may not be generalizable to all settings. Outcomes for patients with public insurance may be specific for Massachusetts Medicaid plans, which have relatively comprehensive coverage compared with Medicaid plans in other states, and the private insurance plans may also differ from insurance coverage elsewhere.

    Clinical significance

    Tumor necrosis factor inhibitors are increasingly being used for cases of JIA refractory to conventional disease-modifying anti-rheumatic drugs, as well as first-line treatment options. Uveitis is a common finding in JIA, for which ophthalmologists often collaborate with rheumatologists in caring for children with the disease. Delays in initiation of TNFi therapy are increasingly encountered as these agents gain wider use, and the impact on systemic and ocular health outcomes merits further study.