Big Win for Patients: Aetna Drops Prior Authorization for Most Cataract Surgeries

American Academy of Ophthalmology looks to build momentum on national, bipartisan reform bill to ensure timely access to care

SAN FRANCISCO, June 30, 2022 /PRNewswire/ -- After a year of sustained advocacy from the ophthalmology community, Aetna announced this week that it will no longer require pre-approval for cataract surgeries starting July 1, 2022, except for people enrolled in Medicare Advantage in Florida and Georgia*. While it remains unclear why these two states are excluded from the rollback, the American Academy of Ophthalmology will continue its effort to protect all patients from abusive prior authorization policies.

Last July, the nation's third-largest health insurer instituted a sweeping and unprecedented new policy requiring pre-approval for all physician-prescribed cataract surgeries. The policy applied equally among its members, from children born with cataracts, to adults whose cataracts interfere with their ability to drive, to people in need of emergency cataract surgery before vision-threatening retinal conditions can be treated.

The impact was swift and chaotic. The Academy estimates that 10,000 to 20,000 Aetna beneficiaries had their cataract surgery unnecessarily delayed in the month of July alone. Since then, the Academy has heard countless stories of patients who were delayed or denied sight-restoring care.

"Aetna's decision to impose a prior authorization requirement for cataract surgery was very difficult to understand since the indications for surgery are well established and the benefits clear," said Stephen D. McLeod, MD, CEO of the Academy. "And the immediate impact on patients subject to unnecessary delay should have been obvious: this is an incredibly common procedure with some 4 million Americans undergoing cataract surgery each year. It has an extremely high success rate with regards to safety and vision improvement, and studies have consistently shown that cataract surgery improves quality of life, lowers the risk of falls and car accidents, and is associated with reduced cognitive decline amongst older adults"

The Academy teamed up with the American Society of Cataract and Refractive Surgery to provide documented patient cases and membership data that substantiated the need for Aetna to rescind its disruptive policy. Both organizations amplified the voices of patients across the country who were harmed by unnecessary care delays and ophthalmologists whose practices struggled under a burdensome approval process that prevented needed treatment.

Advocacy efforts included meeting with the Centers for Medicare & Medicaid Services to request increased oversight and working with bipartisan Congressional leaders to advance the Improving Seniors' Timely Access to Care Act of 2021 (H.R. 3173/S. 3018).

Today, support for this common-sense legislation, which will put important guardrails around prior authorization, has grown to include more than 300 U.S. House members and 34 U.S. Senators. The legislation has been endorsed by nearly 500 patient, provider, and other advocacy organizations.

"We thank the original sponsors of the bills, Representatives Suzan DelBene (D-WA), Mike Kelly (R-PA), Ami Bera, MD (D-CA), and Larry Bucshon, MD (R-IN) as well as Senators Roger Marshall, MD (R-KS), Sherrod Brown (D-OH), Kyrsten Sinema (D-AZ), and John Thune (R-SD), for their steadfast leadership in advancing legislation that will help to ensure our nation's seniors continue to receive the high-quality, timely care they deserve," said David Glasser, MD, the Academy's secretary for Federal Affairs.

If enacted, the legislation would streamline and standardize prior authorization in the Medicare Advantage (MA) program, providing much-needed oversight and transparency while protecting beneficiaries from unnecessary care delays and denials. The legislation would require Medicare Advantage plans to:

• Establish an electronic prior authorization (ePA) program and require MA plans to adopt ePA capabilities, including the ability to provide real-time decisions;
• Annually publish specified prior authorization information, including average response time and the percentage of requests approved, to improve transparency;
• Ensure prior authorization requests are reviewed by qualified medical personnel; and
• Protect beneficiaries from any disruptions in care due to prior authorization requirements as they transition between MA plans.

While the Academy is encouraged by Aetna's reversal and hopeful that federal reform legislation will be enacted into law, Academy leadership remains vigilant in the ongoing battle to protect patients and physicians from abusive health insurance practices.

*Cataract surgery for Florida and Georgia MA beneficiaries will still require prior authorization through iCare.

SOURCE American Academy of Ophthalmology