Larger steps are being taken to reform prior authorization under the Medicare Advantage program. A House committee approved the Improving Seniors’ Timely Access to Care Act of 2022 to advance to a floor vote on July 27. But there is still critical work to be done.

Prior authorization requirements remain despite a report from the U.S. Department of Health and Human Services' Office of Inspector General which indicated that thousands of patients whose care was denied through prior authorization did in fact meet Medicare guidelines.

After strong protest from the Academy and its members, Aetna announced that starting July 1 it would stop requiring prior authorization (PDF) for cataract surgery, except for Florida and Georgia Medicare Advantage members.

Documentation deficiencies have long been cited in post-payment review of cataract surgery. First Coast Medicare administrative contractor (MAC) lists cataract surgery on its current target probe and educate (TPE) action list. Results will be posted once statistics are compiled. TPE audit results from neighboring states MAC Palmetto GBA are highlighted in the Academy’s short video Cataract Documentation Checklist, presented by Ravi Goel, MD. Private Medicare Advantage plans like Aetna expect to reap savings from these errors.

Whether or not you are subject to an audit or seeking prior authorization, medically necessary documentation is required. Now is the time to review the current documentation protocol to ensure that missed documentation does not result in lost practice revenues.

Aetna Medicare Advantage (including dual Medicare-Medicaid) members in Florida will require prior authorization for outpatient procedures — cataract surgery and complex cataract surgery. Review of prior authorization requests are conducted by iCARE Health Solutions LLC.

Providers will submit a request through an online portal (or may fax in documentation if unable to otherwise correspond). Requests must include medical records and identify the requested service.

Criteria established in Medicare Local Coverage Determinations (LCD) guidelines (First Coast MAC) will serve as the basis for determination. Links to current LCD and related articles can be found at aao.org/lcds.

• Cataract Surgery (66984 and 66982) — L38926
• Article for Billing and Coding Cataract Extraction (including Complex Cataract Surgery) — A58592
• Article for Response to Comments: Cataract Extraction (including Complex Cataract Surgery — A58765

See also:

• First Coast Checklist: Cataract extraction

Required documentation of medical necessity for visually symptomatic cataract:

• Chief complaint, including the unique impact on patients’ daily living and/or participation restrictions (including, but not limited to reading, viewing television, driving, or meeting vocational or recreational needs)
• Best corrected visual acuity recorded at distance or near, if the visual impairment is near 
• Cataract grade
• Impairment of visual function is not correctable with tolerable change in glasses or contact lens.
• Cataract is believed to be significantly contributing to the patient’s visual impairment
• The patient desires surgical correction.
• Risks, benefits, and alternatives have been explained
• A reasonable expectation exists that lens surgery will significantly improve both the visual and functional status of the patient.
• When concomitant ocular disease is present (e.g., macular degeneration, glaucoma). indicate that the cataract is believed to contributed to the visual impairment. 

Submitting a Preauthorization Request 

Preauthorization requests can be submitted online or via fax:

• Online: iCare Health Solutions portal – ehealthdeck.com/ 
• Fax: 305.675.8010 

Academy Solutions

Engage Academy consultation services for chart audits and documentation reviews.

Accurately code tests and segment surgical procedures using the 2022 Coding Assistant: Cataract and Anterior Segment.

Ultimate Documentation Compliance Training for Scribes and Technicians is the comprehensive online course that transforms practice staff into a “compliance shield.”

Academy Resources

Find current cataract requirements for your Medicare administrative contractors at aao.org/lcds

Follow current audit focus at aao.org/audits

Fact Sheet for Documenting the Need for Cataract Surgery

Cataract Controversies — Answers to Contentious Coding Questions

Survive and Thrive: How the Academy Helped Us Successfully Pass a Cataract TPE Audit — An Interview With Julia Lee, JD