Georgia Ophthalmologists: Prepare for Humana Cataract Surgery and YAG Laser Prior Authorization on Aug. 1

As the Academy continues discussions with Humana, ophthalmologists in Georgia should prepare for Humana’s Medicare Advantage plans to begin implementing a prior authorization requirement on Aug. 1 for cataract and YAG capsulotomy procedures. 

Humana is the latest Medicare Advantage plan to require prior authorization for cataract procedures Joining Aetna in its focus on Georgia. After strong protest from the Academy and its members, Aetna last month announced that starting July 1 it would stop requiring prior authorization (PDF) for cataract surgery, except for Florida and Georgia Medicare Advantage members.

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

Documentation deficiencies have long been cited in post-payment review of cataract surgery. A recent targeted probe and educate (TPE) audit by Palmetto on Extracapsular Cataract Removal With Insertion of IOL (April-June 2021) showed a denial rate of 25.67%. These audit results are highlighted in the Academy’s short video Cataract Documentation Checklist, presented by Ravi Goel, MD. Private Medicare Advantage plans like Humana and Aetna expect to reap savings from these errors.

It is time to review current documentation protocol to ensure that prior authorization requirements don’t result in lost practice revenues.

Now, effective Aug. 1, for Medicare Advantage (including dual Medicare-Medicaid) members in Georgia, Humana will require prior authorization for three categories of outpatient procedures — cataract surgery, complex cataract surgery and YAG Capsulotomy. Review of prior authorization requests will be conducted by iCARE Health Solutions LLC.

This is the same third party that has managed Aetna’s prior authorization in Georgia over the past year, and practices should already have had experience with its portal.

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 (Palmetto 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) — L34413
• Article for Billing and Coding (Simple) Cataract Surgery — A56613
• Article for Billing and Coding Complex Cataract Surgery — A53047
• Palmetto GBA Cataract Documentation Worksheet
• YAG (Laser for Secondary/Recurring Cataracts) Capsulotomy (66821) — L37644
• Article for Billing and Coding YAG Capsulotomy — A56792

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 cataract 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 www.aao.org/lcds
Fact Sheet for Documenting the Need for Cataract Surgery 
Cataract Controversies — Answers to Contentious Coding Questions