UnitedHealthcare will soon implement a controversial prior authorization policy for surveillance and diagnostic colonoscopies

On June 1, UnitedHealthcare, the nation’s largest health insurer by membership, will implement an advance authorization policy for surveillance and diagnostic colonoscopies. The new coverage policy requires any UnitedHealthcare enrollee seeking surveillance and diagnostic colonoscopies to detect cancer to first obtain pre-approval from the insurer.

This policy does Not apply to screening colonoscopy, which is the routine procedure generally conducted once every ten years to examine the large intestine for ulcers, polyps, and cancer in low-risk members of the general population aged 45 to 74 years.

What makes the new policy on surveillance and diagnostic colonoscopy particularly controversial is that it goes against the grain of what industry experts – gastroenterologists, but also health economists – would consider a rational path. Erecting barriers to access for those who are at risk and therefore more likely to develop colorectal cancer makes no sense.

In particular, surveillance colonoscopy is indicated for people who have a personal history of colorectal cancer or polyps, or conditions that predispose them to colorectal cancer. Also, diagnostic colonoscopy is used for people with symptoms of cancer or those who have had a positive stool test or found polyps in routine screening colonoscopies.

A UnitedHealthcare spokesperson defends the policy as follows: Numerous clinical studies have shown excessive or unnecessary use of unscreened GI endoscopy procedures that can expose our members to unnecessary medical risk and additional costs.

While there may be concerns about the cost-effectiveness of screening asymptomatic individuals at low risk for some types of cancer, there is no question that individuals at risk for colorectal cancer should be screened and that it is convenient to do. Indeed, surveillance and diagnostic colonoscopies for high-risk individuals have been an integral part of clinical practice guidelines for quite some time. Furthermore, surveillance colonoscopy is convenient for patients at high risk of developing colorectal cancer.

Notably, prior to this year, Medicare had a somewhat similar coverage policy, which was heavily criticized and later rescinded. Previously, Medicare would pay for, for example, a Cologuard test, used to periodically screen adults 45 and older who are at average risk of colorectal cancer by detecting certain DNA markers and blood in stool. But if the test result was positive, Medicare wouldn’t necessarily pay for a follow-up colonoscopy.

Recently enacted policy changes require Medicare and most commercial insurers to pay for colonoscopy after a positive Cologuard test at no out-of-pocket expense to the patient. This change was effective January 1, 2023. The update to expand Medicare coverage policies for colorectal cancer screening explicitly aligns with recent recommendations from the United States Preventive Services Task Force and society professional medicine. This includes expanding Medicare coverage for some colorectal cancer screening tests by reducing the minimum payment age and the coverage limit from 50 to 45. Second, it expands the regulatory definition of colorectal cancer screening tests to include what is considered a comprehensive colorectal cancer screening, where a follow-up colonoscopy after a colon cancer diagnostic test Medicare-covered stool-based rectum returns a positive result.

Prior Authorization

UnitedHealthcares’ new protocol will not eliminate reimbursement for surveillance and diagnostic colonoscopies. Prior authorization is not the same thing as exclusion from coverage.

When used judiciously, prior authorization is intended to be a check on the excessive use of technologies and services in the health care system. Insurers like UnitedHealthcare say that by requiring doctors to demonstrate that an operation is medically necessary before agreeing to cover it, they can prevent overuse of medical technologies and services that patients may not actually need. Alternatively, insurers can push doctors to use other, less expensive alternatives.

But this presupposes that the alternatives work as well or better than the intervention placed under a preventive authorization protocol. And in the case of surveillance and diagnostic colonoscopies for at-risk individuals, that presumption is far from obvious. Additionally, prior authorization tends to be a fairly hard-hitting tool that doesn’t work well as a cost-containment measure. To illustrate, on appeal, of 35 million early authorization requests to Medicare Advantage Plans in 2021, 82% were reversed.

In the end, prior authorization in cases like the one at issue in this article isn’t conducive to better medicine practice or a cheaper way to test for colorectal cancer. Indeed, by creating more paperwork and confusion, it is likely to cause a backlash in which healthcare professionals and patients are greatly dissatisfied. In turn, this could lead to a policy reversal, just like we saw with Medicare.

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