For patients with retinal diseases, delays carry consequences.

Conditions such as wet age-related macular degeneration, diabetic macular edema and retinal vein occlusion can progressively damage vision over time, making prompt treatment a central goal of care. Yet a study co-authored by Houston Methodist retina specialist Dr. Charles Wykoff found that prior authorization requirements for commonly used anti-VEGF therapies frequently delay treatment despite ultimately being approved in the overwhelming majority of cases.

The findings raise an important question for healthcare stakeholders: when treating progressive vision-threatening diseases, do the benefits of prior authorization outweigh the burden on patients, physicians and care teams?

Published in JAMA Ophthalmology, the study examined more than 2,200 prior authorization requests for anti-VEGF medications submitted across nine retina practices in the United States. The research revealed a striking pattern: more than 96% of requests were ultimately approved, yet nearly 60% resulted in delays of more than 24 hours, and 40% were not approved on the same day the care was initially planned.

For retina specialists, those delays can create challenges that extend far beyond paperwork.

"When patients have lost vision from conditions like wet AMD or diabetic macular edema, they understandably want treatment as quickly as possible," explains Dr. Wykoff. "The approval process, as it currently stands, may be causing delays and disruptions to treatment as an unintended consequence."

The study was designed to quantify what many retina physicians have long experienced anecdotally: the administrative burden associated with obtaining approval for standard-of-care anti-VEGF therapies. Researchers found that a median of 100 minutes of staff time was required for each authorization request. Across the participating practices, more than 1,700 staff hours were spent navigating approvals during the study period.

Importantly, the overwhelming majority of requests ultimately received approval. Only 3.8% were denied because of step-therapy requirements, and less than 1% were denied because of uncovered diagnoses.

The findings raise important questions about whether some aspects of the approval process could be streamlined without compromising appropriate oversight?

“The answer is not necessarily to eliminate safeguards, financial or otherwise,” emphasizes Dr. Wykoff. “Insurance providers can face legitimate pressures to manage healthcare costs and ensure appropriate utilization of expensive therapies.”

But seeing this data together in black and white can help inform discussions about where administrative processes may be creating unintended consequences for patients and their care teams.

"There needs to be a balance. Payers are trying to be responsible stewards of healthcare resources while also making care more efficient. Real-world data helps move those conversations beyond anecdotes."

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Dr. Charles Wykoff, retina specialist

For retina specialists, the impact is especially acute because many of the diseases treated with anti-VEGF therapy can cause progressive and irreversible vision loss. While a delay of several days or weeks may seem modest on paper, earlier treatment is generally associated with better outcomes across many retinal conditions.

The burden also falls disproportionately on already overburdened clinical teams. Physicians, technicians and administrative staff spend substantial time completing forms, gathering documentation and communicating with insurers — time that could otherwise be devoted to patient care.

Dr. Wykoff also noted that the process can sometimes create confusion for patients, who may not understand why treatments recommended by their physician might not be approved by their insurance.

Ultimately, Wykoff sees the study as an opportunity to improve care delivery through evidence-based dialogue.

"We're simply trying to put data into the conversation," says Dr. Wykoff. "These are real-world challenges that physicians and patients experience every day. Understanding the scope of the problem is the first step toward building a more efficient system for everyone involved."