After surgeons and their professional organizations mobilized and barraged Aetna with a laundry list of horror stories and complaints stemming from the insurer’s attempt to require pre-certification for cataract surgery, Aetna eventually rescinded this unpopular new policy.

“There’s a tremendous feeling of relief,” says Parag Parekh, MD, an ophthalmologist in State College, Pennsylvania, and chair of the American Society of Cataract and Refractive Surgery Governmental Relations Committee. “There was concern that prior authorization policies for ophthalmic procedures would spread to other insurers. That would mean more bureaucracy that wouldn’t improve patient care.  The task of caring for patients and restoring their sight becomes more difficult when excessive paperwork is required.”

Dr. Parekh says pre-authorization requirements are always problematic for patients and practices. “It’s one thing when you meet the patient in the office for a consult, and then the surgery is several weeks later. You have time to get this [paperwork] done in this insistence. However,  there are procedures done on the same day, so requiring prior authorization on a laser procedure like YAG would turn one visit into two. This becomes a significant inconvenience for the patient, who is typically older, can’t see well, and needs a relative to drive them to their appointment. There may also be additional charges for the patient (and insurer) since there will now be two visits instead of one.

Aetna’s policy regarding cataract prior authorization went into effect July 1 of last year and immediately began to cause problems. “This played out in so many frustrating ways,” says Dr. Parekh. “First, before the July 1 start date for Aetna’s prior authorization requirement on all cataract surgeries, providers could not receive approval because Aetna’s electronic prior authorization system, which providers were encouraged to use, was not yet working. In fact, the portal informed providers prior authorization is not required for cataract surgery. As a result, many practices had to reschedule July patients for their surgery because they could not obtain timely approval. ASCRS and the American Academy of Ophthalmology estimated that about 20,000 surgeries had to be rescheduled. Second, the insurer required you to put paperwork above patients by mandating prior authorization on all cataract procedures. There was  already a backlog of patients due to COVID-19, as well as a cohort of baby boomer patients who needed care, so this policy did nothing but exacerbate the current backlog.

Even when a surgeon followed all the proper steps, just the fact that there were extra hoops to jump through could be a problem in and of itself. “We’d file the paperwork and pick a date for the surgery on consultation with the patient,” recalls Dr. Parekh, “and the patient’s family member would take off work that day in order to drive the patient to and from the surgery. However, if we didn’t hear back from Aetna, we’d have to cancel the surgery. Now the family member who had arranged for a day off from work would have to go back and ask to take one off at a later date.”

Dr. Parekh says that, theoretically, prior authorization might make sense in some instances, such as when the physician is deciding whether a patient needs an expensive test or not. “Cataract surgery is black-and-white,” he says. “It is a natural part of aging, and most Americans 65 years or above will undergo the sight-restoring surgery at some point in their lives. Countless studies demonstrate the positive impact cataract surgery will have on a patient’s quality of life. If the insurer denies the surgery, a patient’s vision will get worse—maybe they fall and break a hip or have a car crash. Cataract surgery is proven to bring so much value to our patient’s lives and this why it’s so important they have timely access to care.”

“In the end,” Dr. Parekh continues, “Aetna approved every prior-authorization request we filed for cataract surgery. So, it’s not as if they can say their policy avoided
unnecessary cataract surgery. We jumped through their hoops—which was wasteful—but they approved it all anyway. The extra busywork didn’t benefit anyone.”

In response to the onerous policy, according to an official ASCRS statement on the saga, it and the AAO started a public relations campaign to try to inform the public about the negative impact this policy had on doctors, as well as the dangers of delayed and denied care for Aetna beneficiaries. The eye groups also met with Aetna, questioning the policy’s necessity.

“We met with Aetna multiple times asking for the justification for this,” recalls Dr. Parekh. “We were asking for the data and informing them about how terrible the rollout was. For instance, last June, after we had heard that pre-authorization was going to be required starting July 1st, our staff began looking ahead at our July cataract surgeries to identify patients had Aetna so we could start calling the insurer for pre-approval. In June, Aetna said, ‘Don’t worry about it, no authorization is required.’ But then, on July 1st, suddenly they turned around and said, ‘Yes, that person you called about last week needs prior-authorization.’ ”

Dr. Parekh explained to the insurer that each call for prior authorization took upwards of 30 minutes, since all the data needed to be given to the representative. “So, we met with Aetna to explain the absurdity of this, and ask them to get their internet portal working, and to just tighten up their procedures for prior authorization.

“To decide on prior authorization, Aetna wasn’t even asking the right questions regarding cataract surgery,” Dr. Parekh continues. “If you want to have a prior prior-authorization plan, there are certain things you need to ask the surgeon about: One is visual function, and the other is glare. For instance, as we know, with a high-contrast image in good lighting, a patient’s vision can be decent. But when that person is driving at night their vision significantly plummets. However, Aetna’s representatives weren’t even asking these things when deciding on the appropriate time to do surgery. On some occasions where we’d get denied and have to talk to a doctor to plead our case, the doctor they made available wasn’t an ophthalmologist. For all these reasons, during our meetings with Aetna we’d try to explain to them that they needed a program grounded in clinical care.”

In response to relentless pressure from ophthalmologists, the American Academy of Ophthalmology, ASCRS and Rep. Mariannette Miller-Meeks, MD (R-IA) and Sen. Rand Paul (R-KY), Aetna has pulled the pre-authorization policy for cataract surgery in 48 states—only Georgia and Florida surgeons are still required to get pre-authorization for Medicare Advantage patients, for reasons that aren’t entirely clear.

Dr. Parekh is pleased with the outcome overall, however. “I am very happy to see this policy overturned, especially for my patients,” he says. “My commitment is to provide the best care, and I will continue to advocate on behalf of my patients to ensure timely access to care.”


Risk Factors for Astigmatism in Children with Chalazia

A study of chalazia in children found different characteristics can be risk factors for astigmatism. 

The study included 398 patients (6 months to 6 years old) divided into a chalazion group (n=491 eyes) and a control group (n=305 eyes). The researchers classified the chalazia by site, size and number and analyzed each patient’s refractive status.

They found that the incidence, type, astigmatism and refractive mean in the chalazion group significantly differed from the control group.

Findings in affected eyes included:

  • Incidence: The middle-upper eyelid was 50 percent (the highest) and the medial-upper eyelid was 42 percent.
  • Type: There were more medium (54.5 percent) and large (54.7 percent) chalazia than in controls (27.2 percent).
  • Astigmatism: With multiple chalazia, the astigmatism incidence with two masses was 56 percent. The difference wasn’t significant in chalazia with ≥3 masses. “Astigmatism vector analysis can intuitively show the differences between groups,” the researchers noted in their paper. “The results are the same as refractive astigmatism.”
  • Refractive mean: The medial-upper, middle-upper and medial-lower eyelid were higher than the control group. The 3 mm to 5 mm and >5 mm groups were higher than the control group and <3 mm group. The >5mm group was larger than the 3 mm to 5 mm group. The researchers pointed out that this suggests “that the risk of astigmatism was higher when the size of the masses was >5 mm.”

The researchers concluded that chalazia in children can easily lead to astigmatism, particularly against-the-rule astigmatism and oblique astigmatism. The identified chalazia in the middle-upper eyelid, those ≥3mm in size and multiple chalazia (especially two masses) as risk factors for astigmatism.