Prior Authorization for Eye Treatments Raises Costs | ASRS 2025

The prior authorization process that is required for anti-vascular endothelial growth factor (anti-VEGF) therapies did not save costs but actually increased total societal costs, according to data presented at the American Society of Retina Specialists (ASRS) annual meeting being held in Long Beach, California.

Ella H. Leung, M.D.

This analysis found that insurance companies were the only sector to save money from prior authorizations, but their savings were small and did not negate the increased costs to the rest of society, Ella H. Leung, M.D., with Georgia Retina, said during a session.

Anti-VEGF treatments reduce blood vessel leakage and growth in the eye and are used to treat macular degeneration, diabetic retinopathy, retinal vein occlusion and macular edema.

Leung and her colleagues wanted to evaluate the economic impact of prior authorizations for anti-VEGF therapies. They conducted a retrospective analysis on prior authorization delays and denials from the SamaCare PA electronic database. SamaCare is a cloud-based platform that automates and streamlines the prior authorization process for medical practices.

Researchers then created a theoretical cost model to calculate the increased total societal costs from prior authorizations, including formal healthcare, informal healthcare, and non-healthcare costs. Lost patient and caretaker wages, lost productivity, transportation costs, staffing costs and interest accrued from delayed or denied anti-VEGF therapies were also included as part of the model.

Leung said they assessed 33,000 prior authorizations, of which the majority were eventually approved. “But 2.35% of them were denied, and the majority were from Medicare Advantage and commercial carriers,” she said. “The prior authorization process was ultimately causing significant delays for our patients. The majority were ultimately approved, though, but it can cost our patients and our society money.”

Researchers found that over the average patient’s lifetime, the prior authorization process increased the total societal costs by an average of $10,016, and the direct savings from denying a prior authorization was only $28.90 per injection per year. Prior authorization was not cost-saving in more than 99.9% of the modeled scenarios the researchers conducted. Insurance companies were the only sector of society to potentially save money.

In their analysis, the workplace and the patients are the ones who carry the greatest burden from these increased costs, Leung said. Each prior authorization request increased the total societal costs by an additional $626.02 per year, costing the workplace an extra $491.86, the patient $292.71, the provider $27.35, and the insurer $5.65 per year.

This analysis comes at a time when insurers are facing increased scrutiny over prior authorization processes and denials. Insurers have announced plans to reduce prior authorization requirements and establish a faster process for approvals. In June 2025, CMS and more than 50 insurers pledged to streamline and simplify the prior authorization process through six new commitments. Plans such as Aetna, Cigna, Humana, UnitedHealthcare and the Blue Cross Blue Shield plans have signed on to provide faster and more direct access to medical services.

Some changes, such as reducing the scope of claims subject to prior authorizations and enhancing communications and transparency, are expected by Jan. 1, 2026. Other changes, such as expanding real-time response and standardizing electronic prior authorization, will be implemented by Jan. 1, 2027.

The changes will be implemented across insurance markets, including for those with commercial coverage, Medicare Advantage and Medicaid managed care, and are expected to impact about 257 million Americans.

“CMS announced that they’re trying to work with insurance companies to try to decrease the number and the burden of the prior auth,” Leung said during the session. “We’re all hopeful that that will work. But there are other things that we can do as well…things like getting prior auth ahead of time, if possible.”