Proposed policy would impact blepharoplasty, blepharoptosis repair, brow ptosis repair and BOTOX injection services in 10 states.
The Centers for Medicare & Medicaid (CMS) have proposed initiating a 5-year demonstration project (Prior Authorization Demonstration for Certain Ambulatory Surgical Center [ASC] Services [CMS-10884]) that will require ASCs to receive prior authorization (PA) for Part B Medicare carriers for services that include blepharoplasty, blepharoptosis repair, brow ptosis repair and botulinum toxin injection. The project will encompass these services in Arizona, California, Florida, Georgia, Maryland, New York, Ohio, Pennsylvania, Tennessee and Texas. The CMS does not anticipate the changes taking effect before fall 2024.
In a joint letter to the CMS, the AAO, Outpatient Ophthalmic Surgery Society (OOSS) and American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) expressed significant concerns about expanding PA requirements to the ASC care setting and urged that the CMS halt implementation of the demonstration.
In the letter, the AAO, OOSS and ASOPRS stated that the plans outlined by CMS will erect barriers to accessing medically necessary care for Medicare fee-for-service beneficiaries. The organizations also stated that the planned demonstration ignores important lessons learned from the hospital outpatient department (HOPD) PA program and is deeply flawed due to:
- Unresolved problems with the HOPD PA program
- Insufficient evidence to support the rationale for PA in the ASC setting, including lack of demonstrated evidence of fraud for provision of these services in the ASC
- Failure to include lessons from the HOPD PA program, inaccurate administrative burden estimates
- The potential for patient harm due to delayed care.
In a letter to its members, OOSS further clarified the key points outlined in the joint letter, stating:
- The HOPD PA program must be further evaluated and improved before extending PA to surgery centers.
- CMS should remove all ophthalmic procedures (ie, the codes listed under (i) Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair and (ii) Botulinum Toxin Injection) from the ASC PA Demonstration.
- The agency has significantly understated the true administrative burden of compliance with the Demonstration and overlooks many other problems associated with PA, including treatment delays and blocked patient access to medically necessary care.
- Since the ASC does not possess the requisite patient records that support the need for surgery, CMS should clarify that the practice, not the ASC, is responsible for obtaining the PA.
In a statement released to its members, the AAO says, “The Academy will come out strongly against adding a new administrative burden for Medicare services in the ASC setting, highlighting our members’ tumultuous experience with HOPD prior authorization.”
Melissa Toyos, MD, partner and research director of Toyos Clinic in Nashville, Tenn., performs these procedures in office, except for potentially medically unstable patients. She says this proposal adds an additional administrative burden for practices.
“I can say this is disappointing but not surprising. It seems to be one more action in a series to add to the back-breaking administrative burdens practices currently face and is designed to delay care for our patients. I hope it follows in the path of the proposed PA regulation Aetna recently tried to impose on cataract surgery [that was later rescinded].” OM
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