Jul 9, 2024
Apr 15, 2025
Written By Elizabeth Cifers
So, one of your retina physicians selected a drug that requires prior authorization (PA). Now what? While approval isn’t guaranteed, proper chart support for the medical necessity of the medication chosen can ensure a faster turnaround if the payer requests the chart note before providing a PA, and it will quicken appeals if the claim is denied. Please keep reading to learn why some retina drugs require a PA and what information to include in the documentation for medical necessity.
Some Medicare Advantage and commercial insurance payers require a pre-approval process to determine coverage for a particular service. In a retina practice, these insurance practices mainly impact injections and surgical procedures.
In addition to the PA, these same payers may require step-therapy, or try-and-fail, for a lower-cost drug before a branded, more expensive drug. Alternatively, some payers may require step therapy but no PA. For example, the payer may require the use of bevacizumab for any indication that an anti-VEGF might be used, but they may not need a pre-auth for this first-line injection due to the low cost.
Almost every payer will have try-and-fail criteria, some more specific and others very general. It is imperative to stay up-to-date with payer requirements as they may change.
The theory of a PA is to keep costs contained while ensuring a positive patient outcome, which is a fiscally prudent concept. However, it can be challenging to obtain a PA if details for the requirements or in the documentation are glossed over, which will create additional work on the practice in the form of appeals and potential loss of payment for the procedure or drug.
The information required in the chart to support the medical necessity of a drug PA is consistent across payers. All payers will expect to see the following:
See How to Improve Medical Documentation at Your Retina Clinic for general documentation tips.
If you encounter a retina drug that requires prior authorization, don’t panic. The physician's documentation should support the medication's medical necessity, with complete chart documentation for why the medication is selected and the anticipated outcome. Reviewing the payer’s policies for any potential step edits (try-and-fail) and their criteria is essential. Additionally, what are the preferred drugs for the payer? The physician will want to know the options should the first drug fail to provide a positive outcome for the patient.
Your retina practice’s chart documentation should support every billed drug, CPT, and diagnosis code. When it’s inadequate, one possibility is delayed or denied reimbursement; however, another is a risk of recoupments resulting from the findings of a payer audit.
Learn more about payer audits by downloading our Chart Audit Brief, assess your risk by purchasing our Chart Audit Risk Analysis Tool, or consider hiring a consultant like Elizabeth Cifers to help identify risks. Elizabeth has decades of experience in medical administration, including 13 years at a retina practice and a position at a leading eye care consulting firm. See what Elizabeth can do for you in a free call: book here.
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