Medicare Advantage Prior Authorization Requirements for Otolaryngologic Procedures

Introduction: Medicare Advantage (MA) allows beneficiaries to enroll in private health plans and is now the primary means by which Medicare patients receive coverage. MA insurers commonly implement prior authorization (PA), which requires providers to demonstrate the necessity of services prior to provision as a condition for reimbursement. We sought to understand the extent to which MA insurers require PA for commonly performed otolaryngologic procedures.

Methods: We performed a secondary analysis of data comparing PA policies across five major MA insurers. These data were manually extracted from publicly available insurer policy documents in 2021 and specify for all services described by HCPCS codes whether PA was required (yes/no). We focused analysis on the procedures most often performed by otolaryngologists, which we identified using the Medicare 2021 Physician/Supplier Procedure Summary dataset. We estimated the proportion of Medicare Part B fee-for-service spending and utilization that would have required PA if all beneficiaries were covered under the rules specified by each MA insurer.

Results: Otolaryngologists provided 196 unique services. Medicare Part B fee-for-service spending and utilization for these services totaled $505.7M and 4.1M procedures. The counterfactual proportion of spending (range: 20.4%-27.6%) and utilization (1.8%-4.5%) requiring PA was relatively consistent across insurers. However, coverage for specific services and disease areas varied widely among insurers. For example, 4 insurers stipulated minimal prerequisites for ablative head & neck procedures, but the fifth insurer imposed significant PA requirements. If rules were restricted to only the services designated by all insurers, a much lower proportion of spending (9.2%) and utilization (0.3%) would require PA.

Conclusions: While insurers uniformly required PA for procedures that may be prone to overuse or demand careful patient selection, coverage rules varied widely. Such discrepancies illustrate the challenges of navigating discordant insurer policies for otolaryngologists.