If someone were to ask me what has been the bane of my existence since starting practice, there’s one singular factor that comes to mind.
It’s not getting a corneal abrasion
after dilating a feisty 5-year-old. It isn’t the constant turnover of technicians and staff that plagues nearly every office post-pandemic. Surprisingly, it’s not even the new progressive addition lens (PAL) wearers that come back to me for re-refracts after ordering their glasses online.
The single bane of my new practice experience has been obtaining prescription drug coverage. Namely, dealing with coverage denials and their reasons.
How to approach prescription drug coverage as a new optometrist
No one covered this frontier in school
or in residency
. The class Ocular Pharmacologics: Getting Insurance Companies to Remember You Have a Degree
never showed up on my transcript. Nevertheless, as a doc who manages A LOT of dry eye and glaucoma, it’s a problem I face weekly.
As a 1099 contractor, I used to do a lot of my own prior authorizations (PAs) for dry eye medications
, and even continued to do a majority of them well into my second year of practice. Why? Firstly, I realized what we all come to realize: pharmaceutical coverage is a game, and by doing my own PAs, I was able to learn how to play. As I entered the insurance and saw their outcomes, I established trends in their coverage patterns.
“Initially, I even kept a more formal spreadsheet to keep track of the insurance companies’ specific requirements.”
Upsettingly, I came to realize that the biggest pushback came from the health insurance associated with one of our largest hospital systems. I learned that with state insurance (Medicaid especially), you can’t jump steps (Restasis first), and 3-month supplies of dry eye medications would be a no-go (try 30 days, 60 vials with three refills). The most lenient coverages would come from large commercial employers, often approving Xiidra on a first-try basis. And with high deductible plans—all bets were off.
The most recent twist has come with attempting coverage for Oxervate, an FDA-approved ophthalmic medication for the treatment of neurotrophic keratitis
(NK). Coming in at a cost of ~$1,732 per vial, with seven vials per week for 8 weeks, it’s no surprise that the coverage process is so rigorous. But knowing the proper ways to detect, document, and appeal for Oxervate will ease you through the prior authorization process.
Detecting and diagnosing neurotrophic keratitis
Fortunately, awareness of NK is on the rise. You can’t open a major eyecare magazine without seeing at least one article about it—which is GREAT! But reading about it is one thing, and implementing treatment of the condition into daily practice is another. The largest tip I can give for a comprehensive dry eye evaluation is to bring patients back for a separate medical office visit.
When you’re new to dry eye, you need time to accurately assess various ocular surface disease states, whether that be aqueous deficient dry eye disease (ADDE), meibomian gland dysfunction
(MGD), neurotrophic keratitis, and/or neuropathic pain.
Somewhere in my training, I remember being told that “NK is pain without stain,” which may be true in the early stages, but I’ve since moved away from that way of thinking. If we look at the staging system, NK is more about epithelial defects
where the patient's symptoms are minimal compared to their ocular surface. This indicates a hypoesthesia of the cornea, indicative of neuralgia.
This distinction is important because while Oxervate is FDA-approved for all stages of NK, the REPARO study
only looked at patients with Stages 2 and 3 of neurotrophic keratitis. Because of this, insurance companies will frequently deny coverage for Oxervate for Stage 1 of NK.
Staging for neurotrophic keratitis:
- Stage 1: Epithelial changes
- Stage 2: Persistent epithelial defects
- Stage 3: Corneal ulceration
Testing patients for neurotrophic keratitis
Vital testing also includes corneal sensitivity. While various methods exist, what’s most accessible to me is a cotton-tipped application. I use my forceps to pull the fibers apart, which often results in one long fiber and three to four shorter fibers behind it.
At the slit lamp, I ask the patient to disregard the visual aspect of the fibers coming toward them but to vocalize when they feel a sensation. I start with one fiber and gradually increase, adding more fibers until the patient vocalizes a sensation. For example, a severe patient may indicate a sensation when three to four corneal fibers have touched.
“I find this ‘fiber method’ gives good quantitative information for an otherwise nonstandardized test.”
I also try to test all four quadrants: temporal, inferior, nasal, and superior. This is especially important since, during the PA stage, insurance companies will sometimes ask for the specific quadrant in which there is reduced sensitivity. It can also be handy to document the duration of the epithelial defect, as many insurance companies want documentation that an epithelial defect has been present for at least 2 weeks before they will consider approval.
Documenting NK for insurance carriers
There are two ways to start the prior authorization process for Oxervate. You can fill out the physical Oxervate Patient Enrollment Form
and fax it to Dompé CONNECT to Care, or alternatively, set up an account with iAssist to fill out an electronic form. The form includes the two important pieces of information you gathered from your exam: NK staging and corneal sensitivity.
Additional information that should be provided is associated diagnoses codes which can include: central corneal ulcer (H16.01x), unspecified corneal ulcer (H16.00x), neurotrophic keratoconjunctivitis (H16.23x), and/or anesthesia and hypoesthesia of the cornea (H18.81x).
Once that form is sent off, it is likely that the insurance company will reach out with its own clinical form requesting clarification. In one experience, I was asked for failed medications. I listed topical dry eye immunomodulators and biologic drops and promptly received a denial stating there were no artificial tears listed.
Lesson #1: Insurance companies have different definitions of “medications.”
- Documentation Tip #1: On the insurance form, list EVERY THERAPY they’ve ever attempted related to their dry eye (lubricants, steroids, membranes, in-office treatments, serum tears, etc.).
I called the company and clarified the misunderstanding. They processed it only to send another denial stating that there was incomplete information and “Oxervate is clinically indicated for Stages 2 and 3 of neurotrophic keratitis.” I found that to be odd, given that it was included in the original document that I provided through Oxervate.
Nevertheless, I then realized:
Lesson #2: Insurance companies don’t always read your notes and supplemental information outside of what they request.
- Documentation Tip #2: If the insurance company provides you with their own form at any point in the process, carry over past information onto that form.
Navigating the discrepancies of medical billing denials
As frustrating as it is to transfer the information you’ve already provided, it may help you avoid a second denial. With glaucoma medications
, denial reasons can sometimes be as ridiculous as stating formulary alternatives that are contraindicated. For example, I once had a patient who developed fatigue and shortness of breath when increasing their branded brimonidine tartrate 0.2%/timolol maleate 0.5% to twice a day dosing. I decided to switch the patient and obtain coverage for branded brinzolamide 1%/brimonidine tartrate 0.2%.
In my notes, I documented “BB’s contraindicated, prostaglandin analogs contraindicated due to dry eye.” Lo and behold, it was denied due to not attempting alternative formulary options, including timolol maleate 0.5%. Now I think any ophthalmic clinician would clearly understand BB was beta-blockers, and that would mean that timolol was an inappropriate alternative. However, this lesson taught me to never assume that those who are approving or denying medications think the same way you do.
Again, as time-consuming and frustrating as it is, you may want to list out all medications that are inappropriate rather than just the pharmacologic class that they belong to. Example: Prostaglandin analogs (latanoprost, travoprost, bimatoprost, etc.) contraindicated due to exacerbation of dry eye disease.
Appealing medical billing denials
It’s really important to follow everything above because if we get to the process of needing an appeal, that’s where it gets really time-consuming! Most (but unfortunately not ALL) insurance companies offer a peer-to-peer review in which you can speak with another health professional to override the decision.
Some have been frustrating to schedule (suggest times during clinic hours and only attempting to contact you once), yet fruitful when cleared up. Others have gotten nowhere and redirected me to an alternative third-party company to determine the final outcome. If you’re at the point of needing an appeal, it’s best to get out your letterhead and put the ink to paper.
In your letter, include the following:
- Insurance party
- Patient’s name
- Patient’s date of birth
- Insured/patient’s policy number
- Appeal reference number
- The drug that you are requesting
The body of the letter should include medical justification or medical necessity for your medications. I reached out to a local pharmacist who recommended a supplemental statement along the lines of, “Formulary alternatives would be less effective for this patient and likely cause side effects.”
In the case of Oxervate, a sample letter can be found here. In the event that it is still denied, Oxervate will assist by working with a rare disease organization to obtain funding for the patient's treatment.
Prior authorizations are often a frustrating and obstructive part of the medical process. Nevertheless, as a field that’s overall poorly understood by other healthcare practitioners, it falls on us to be the best advocates for our patients
I hope this guide serves to lessen the burden and allow you to continue to deliver the best care possible.