Medicare Advantage Prior Authorization Requirements for Otolaryngologic Procedures in 2021

Topic: Risk, prevention and care in population studies

Abstract Little is known about the extent of prior authorization requirements in otolaryngology. We performed a secondary analysis of data comparing prior authorization (PA) policies across 5 major Medicare Advantage insurers to estimate the counterfactual proportion of 2021 Medicare Part B fee‐for‐service spending and utilization for commonly performed otolaryngologic procedures that would have required PA. The counterfactual proportion of spending (range: 20.4%–27.6%) and utilization (range: 1.8%–4.5%) requiring PA was relatively consistent across insurers and largely attributable to rhinologic procedures. However, PA requirements for specific services varied widely among insurers. Among the 70 (of 196; 35.7%) services subject to PA by any insurer, nearly half were subject to PA by a single insurer (n = 34; 48.6%). Only 10 (14.3%) services were subject to PA by 4 (n = 6; 8.6%) or 5 (n = 4; 5.7%) insurers. These discrepancies illustrate the challenges of navigating discordant insurer policies for otolaryngologists and raise concerns about the validity of certain PA requirements.

Key findings

• The counterfactual proportion of spending (range: 20.4%–27.6%) and utilization (range: 1.8%–4.5%) requiring PA was relatively consistent across insurers and largely attributable to rhinologic procedures.
• However, PA requirements for specific services varied widely among insurers.
• Among the 70 (of 196; 35.7%) services subject to PA by any insurer, nearly half were subject to PA by a single insurer (n = 34; 48.6%).
• Only 10 (14.3%) services were subject to PA by 4 (n = 6; 8.6%) or 5 (n = 4; 5.7%) insurers.
• These discrepancies illustrate the challenges of navigating discordant insurer policies for otolaryngologists and raise concerns about the validity of certain PA requirements.

Why it matters

This analysis found that prior authorization requirements for otolaryngologic procedures varied widely among Medicare Advantage insurers, with nearly half of affected services subject to prior authorization by a single insurer. It contains no research findings on treating, curing, or preventing Alzheimer's disease.

Study details

• Participants34
• Effect size20.4%; 27.6%; 1.8%
• Evidence strengthLow

Read the original

• DOI: 10.1002/ohn.931
• Original source →
• Free full text: Otolaryngology →

Full text: free to read — OpenAlex lists this copy as free to read: the link above (checked 6 Feb 1020).

@article{miller2024-1a6183d0,
  author  = {Miller, Lauren E. and Miller, Ashley L. and Rocco, James W. and Rathi, Vinay K.},
  title   = {{Medicare Advantage Prior Authorization Requirements for Otolaryngologic Procedures in 2021}},
  journal = {Otolaryngology–Head and Neck Surgery},
  year    = {2024},
  doi     = {10.1002/ohn.931},
  url     = {https://doi.org/10.1002/ohn.931}
}

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