Ethical Obligations and Duty to Advocate for Patients in Prior Authorization for Surgery

Clinical Scenario

You are seeing a four-year-old female in your pediatric otolaryngology clinic for a pre-operative visit to discuss your request to the state Medicaid/ CHIP office for prior authorization to provide surgical services on her behalf. The patient, Cindy Long, was attacked approximately one year ago by a stray dog in the neighborhood, resulting in multiple, extensive lacerations and deep bites that you repaired in the operating room. Despite diligent scar care (silicone gel massage, steroid injections, and other salutary scar treatments), she has developed a hypertrophic scar along the left upper lip and cheek that distorts her smile and limits oral competence. Additionally, there are at least 15 other unsightly and problematic scars that have caused her to be teased and ridiculed at school. In last month’s evaluation, you noted no further significant improvement on medical treatment and advised the parents on the next recommended step, which would be a course of longitudinal scar revisions over a longer time frame. They concurred and wished to move ahead with the surgery.

In your letter of request for a surgical coverage authorization, you fully identified the impacts of the scars on her quality of life and detailed the reconstructive surgery that would be required, including high-quality photographs. You commented on the functional impairments and the psychosocial harm she has experienced over the past year of healing. The formal request for prior authorization was approved for the left upper lip scar but denied for all of the remaining scars. Denial was based on the payer’s statement that “cosmetic surgery for scarring” is not covered, unless determined by the reviewer to be medically necessary, which the reviewer felt it was not. You filed an appeal for a higher review, with additional documentation, but the denial was upheld. You finally were able to have a telephone conversation with a physician reviewer, but he was a retired adult neurologist and would not be convinced. You explain to Cindy and her parents that Medicaid would authorize the functional scar revision, but not for the disfiguring scars.

Cindy’s parents are obviously quite disappointed and very distraught. Cindy cannot understand, and states, “I want my face to look like a normal girl again.” How can you further advocate for Cindy as an ethical responsibility and professional duty?

Discussion

In one form or another, we have all been faced with what we feel to be incorrect prior authorization determinations, and understand how frustrating it is for the patient, family, and otolaryngologist. One can actually “personalize” the situation, where we empathize with them, owing to substituted empathy, particularly if we have children or grandchildren of our own—it can just hit home.