Aetna policy change requires preapproval for cataract surgeries

Aetna began requiring that healthcare providers get preapproval for all cataract surgeries July 1.

The insurer did not publish updated policy documents before implementing the policy, according to a statement from the American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery, which means some ophthalmologists have had to cancel cases until they can get approval.

The joint statement from the two industry groups said some ophthalmologists were told to cancel surgeries for the first two weeks of July until the procedures could be preapproved, while others were told there was not a policy update.

Aetna told the ophthalmology organizations there is less than a 5 percent chance they will deem surgeries unnecessary during the preapproval process. The ophthalmology organizations oppose the policy change.

The insurer has been under attack by the AAO and ASCRS as the organizations try to get a reason as to why, especially since no other major insurance carrier has felt the need to enact such a policy.

Aetna has only replied that the chance of it deeming a cataract surgery unnecessary is probably less than 5%. This was a last-minute announcement for a policy that Aetna seems unwilling to discuss or delay by even a month to help practices prepare.

The AAO has estimated that 10,000 to 20,000 patients covered by Aetna will have their surgeries delayed in the first month alone.

Thinking about these delays, our mind wandered back to the spring of 2020. During the early days of the pandemic, when all eyes were on the surging infections and subsequent hospitalizations and deaths, severe lockdowns were implemented.

And they impacted most all of us in ophthalmology. Eye care of all stripes was deemed an “essential service,” but as cases began to rise, we made our own decision to shut down — sort of.

We think we all know that a patient who has a significant cataract needs to have surgery in an expeditious manner. People with cataracts have car wrecks, falls resulting in hip fractures and all manner of other incidents.

Sure, some of the patients we see have milder cataracts and just can’t see a golf ball that well. Most of the patients we schedule for cataract surgery are a menace on the road! So why this policy?

Our guess is some actuary realized that even a month’s delay in cataract surgery will produce more revenue for the company and in turn for the stockholders. Face it: at typical cataract surgery age, people’s clocks are winding down.

Any delay can lead to death or even a serious illness that will indefinitely postpone a surgery that the insurer now doesn’t need to reimburse. Some patients will put it off due to the frustration of having to delay scheduling surgery.

Are some cataract surgeries performed unnecessarily? Certainly. We’ve seen multiple cases of one eye operated upon by another surgeon and the patient subsequently came to us for consultation about surgery on the other eye.

Prior records indicated a moderate or severe cataract in the unoperated eye, where our exam revealed 20/20 vision and little or no cataract. And yes, in many practices where the norm is still that the optometrist makes the decision for and scheduling of cataract surgery and the surgeon just shows up to operate, often performing an “eye exam” right before the patient is wheeled to the OR.

But would this Aetna policy reduce unnecessary surgeries? The minority — hopefully the very tiny minority — of surgeons who operate unnecessarily are probably pretty good at poor refractions and shoddy exam documentation, so it’s likely a chart review by a nurse won’t detect any issues.

Thus, we are guessing the purpose of Aetna’s delay is just about money. What do you think? Whatever the motivation, though, these delays, much like those we experienced due to COVID, will do more harm than good.