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.

Prior authorization delays or denial can harm patients both clinically and psychologically. It was important for the otolaryngologist to explain the situation in full transparency so as to support the family’s trust in them, and to also support the parental autonomy and Cindy’s hopes. This scenario brings into view the multi-ethical principlism of beneficence, non-maleficence, and autonomy, but especially justice and equity for Cindy, who deserves equitable access to reconstructive surgery regardless of payer or patient resources.

As physicians first and otolaryngologists second, we are bound by professional duties, guidelines, and expectations from society to consider and represent the patient’s best interests in all aspects of their care. Dealing with insurance payers is one of the least valued of all of our duties, but duty it is. We are ethically obligated to advocate for care that restores function, mitigates disfigurement, and improves psychosocial development and well-being, especially in a child. There is no denying that any aged child or adolescent can face potential appearance-targeted bullying, harassment, or belittlement, and there is plenty of that occurring these days at schools and on social media. Even a four-year-old child such as Cindy can face very hurtful behavior and comments from others that can have a lasting impact on her self-worth and self-confidence.

Other issues of professional duty and ethics involve social justice and full access to care for a patient’s injuries. Denial of medically necessary reconstructive surgery for a child on Medicaid/CHIP raises serious concerns of distributive justice and fairness. In Cindy’s circumstance, the parents would be unable to afford private insurance or even fee-for-service charges to revise the low functional impact scars, which would place a clear and deep burden on their limited financial resources. Children from disadvantaged backgrounds should not face barriers to function- and appearance-restoring surgery that might be readily approved for privately insured patients; however, in reality, even private insurers often deny such procedures that are likely to be costly to them.

Patients are right to expect us to discharge our duties to care for them, even if it involves additional time and effort, and generally appreciate our advocacy on their behalf. The otolaryngologist is the leader of their care team for the longitudinal pathway from injury repair to the ultimate best possible outcome. That trust may require our “going the extra mile” to coordinate their care successfully and to repeatedly earn their trust. Surgeons do not often think of themselves as “patient navigators,” but this term seems to fit this scenario quite well. Poor documentation and preparation of prior authorization requests and appeals can not only be harmful to the patient, but also to the patient–physician relationship, as trust can be eroded and dissatisfaction ensues. Timely and successful prior authorization efforts by otolaryngologists on behalf of their patients are not merely a clerical task; it is also an ethical duty.

Patients expect the timeliness of our efforts, particularly if delay would be detrimental to their health issues. It is also important for the otolaryngologist, whether or not they have had previous denials for similar requests, to anticipate possible payer objections prospectively and to address them in the initial prior authorization request. Certainly, if an appeal is required, every denial objection must be countered with evidence-based data and thoughtfully reasoned responses. At the onset of the prior authorization process, the otolaryngologist would do well to outline for the patient/family the prior approval procedures and any variations owing to public or private payers, to help them understand the mechanisms and where a delay might occur. If second opinions would be helpful for the request or appeals, then that further information-gathering process must be facilitated, especially if it is likely to have a favorable impact on a decision.

Obtaining prior authorization can be a drawn-out effort. Patients and family members may become impatient with delays, so active listening and effective communication by the otolaryngologist are key elements in moving the authorization forward. Timelines expressed to the patient must be realistic, and the risks of delays should be fully explained. Yet, a positive outlook and hope are products of effective otolaryngologist communication skills. Significant delays and denials can be morally stressful for both surgeon and patient/family units, requiring attention to their well-being and continued dedication to the task.

When prior authorization requests and appeals are all denied, then the otolaryngologist needs to redouble their efforts and consider more aggressive and creative approaches. This might include requesting hospital or institutional support, with the claim of overcoming systemic barriers to care, or using federal oversight reports (Office of the Inspector General, state oversight and advocacy departments) in further appeals when denials contradict coverage rules and general best clinical practice guidelines. Engaging with specialty societies’ advocacy experts to join the effort should be in alignment with the societies’ stated mission and goals for patient support, and their advocacy for system-level reforms that reduce arbitrary or indifferent approaches to prior authorization requests on behalf of patients. Finally, while not necessarily encouraged, social platforms that allow donations to families for needed surgery might be the answer.

When otolaryngologists advocate effectively for their patients, they uphold beneficence, prevent harm, respect patient autonomy, and promote distributive justice. Patients judge an otolaryngologist’s commitment to them not only by skill in the operating room, but also by their dedication to removing barriers to their care. For otolaryngologists, as for all physicians, professional and personal integrity are strongly linked in a physician’s approach to fellow human beings.

Little Miss Cindy requires a dedicated approach to her needs and a will to obtain a successful outcome for her. If she were my grandchild, or anyone’s grandchild, she has a right to expect the very best advocacy efforts and surgical skills that can be brought to bear on her future self-worth. It is her happy, functional, and rewarding life moving forward that needs to be front and center in the otolaryngologist’s priority.

Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.