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  • Opinion

    Prior Authorization: Cataract Crisis

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    Ruth D. Williams, MD

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet

    As if we didn’t have enough stress, employee burnout, and unique challenges during the pandemic, last July Aetna implemented prior authorization requirements for cataract surgery. I’ll share three recent stories from my practice that illustrate the poorly designed process and how it harms patients, physicians, and our staff.

    A 71-year-old retired college professor was denied authorization for cataract surgery despite vision of 20/60 in both eyes. While her cataract surgeon, Michelle Kron-Gray, doesn’t know why the patient was denied authorization, she suspects that the Aetna questionnaire didn’t elucidate the patient’s visual disability. For example, the questionnaire asked if she has trouble playing Bingo (no, she doesn’t play Bingo), trouble with night driving (no, she doesn’t drive at night), or trouble recognizing faces (no, she can still recognize faces).

    A week before the surgery, Michelle was on vacation with her family when she received notification of the denial and a peer-to-peer review that same day. Our staff asked to move the appointment, but Aetna refused. Michelle joined the call 20 minutes early and was put on hold for over one hour when she received this message: Your time is expired, and the surgery is automatically denied. After a denial, Aetna will not review an appeal without additional clinical information, which may require another patient visit.

    My glaucoma colleague, Frini Makadia, had a patient with 20/30 vision and cataracts. She can’t drive at night due to the glare, but the real issue was the narrow angle and slightly elevated IOPs. Her anterior chamber depth was 1.98 mm, and she opted for cataract surgery over bilateral laser peripheral iridotomy (LPI) or monitoring without treatment. Autho­rization was denied, and Frini was offered a peer-to-peer review, but when she called to schedule the review, she was asked to leave a message. No one called her back. The patient made two attempts to contact Aetna herself but was frus­trated by call center employees who had no idea where to forward her concern. The patient eventually had bilateral LPIs, but she’ll still need cataract surgery in the future.

    A third colleague, Steve Lafayette, wished to challenge an Aetna denial. Noting the very tight window for scheduling a peer-to-peer review, he patiently waited on hold for over 30 minutes and agreed to a review that was scheduled at 1 p.m., right in the middle of his busy clinic. The reviewer was a cardiologist who didn’t know what OD or OS stands for.

    Prior authorization is not inherently evil. However, there are four problems with the new Aetna process. First, it is more cumbersome and onerous than ever before. The hours that our scheduling staff spend on the phone is frustrating for them and horribly inefficient for our practice. Second, the process keeps changing—and has become even more challenging. For example, Aetna now requires the 18-item patient questionnaire and glare testing (but denied an autho­rization because the testing was performed on both eyes at the same time). Third, the algorithms ignore the decision-making that goes into recommending cataract surgery. Finally, Aetna claims that 20% of cataract surgeries are unnecessary, yet they ignore calls for showing data to support this asser­tion. Aetna’s defense is that they expect to approve more than 90% of the cataract surgery prior authorization requests, which undermines their claim that surgery is unnecessary.

    Other than commiserate with one another, what can we do? To put pressure on Aetna, several of us have pub­lished opinion pieces in our local newspapers. And there’s a bipartisan bill—Improving Seniors’ Timely Access to Care Act (H.R. 3173)—that has 255 cosponsors in the House and has been endorsed by over 450 physician and patient organizations. Among other points, the bill requires a qualified reviewer (not a cardiologist) to review a denial for cataract surgery. Finally, members of Congress need to hear from our patients, who are being denied needed care (for resources, see Prior authorization is not going away, but we can insist that it’s used in a responsible, efficient, consistent, and evidence-based manner.