LUGPA Policy Brief: Reforming Prior Authorization, Aetna’s 2025 Initiatives, and the Ongoing Burden on Independent Urology Practices
December 2025
At-a-Glance Essentials
What’s Changing
Why It Matters
- Independent urology practices continue to face delays, staff burden, and inconsistent decision timelines—especially for cancer treatments, surgery, and advanced imaging.
- Single-payer pilots cannot replace enforceable federal and state reforms.
Action Points
- Document chronic PA delays/denials—particularly in prostate cancer and surgical care.
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- Monitor emerging federal PA transparency rules and state gold-carding laws.
Key Dates
Overview
Prior authorization (PA) remains one of the most significant administrative barriers for independent urology practices. While Aetna announced “streamlining” steps in 2025, these changes do not reduce the number of services requiring PA or the staff time needed to manage them. LUGPA practices report no decline in PA workload and, in many cases, an increase in volume.
Aetna’s initiatives — oncology imaging bundles, medical–pharmacy integration, and internal automation—offer targeted efficiencies but do not meaningfully improve surgical, cancer, or imaging-related authorization processes central to urologic practice.
Summary of Aetna’s 2025 Initiatives
Oncology Imaging Bundles
A single PA now covers multiple MRI/CT studies within an oncology episode, including prostate cancer. This reduces some duplicate imaging requests but does not affect PA for surgery or advanced therapies.
Medical–Pharmacy Integration
Beginning November 2025, approval of certain medical PAs automatically triggers approval of associated pharmacy benefits. This helps a subset of advanced prostate cancer patients but remains limited in scope.
Digital/AI Enhancements
Aetna’s new AI tools and analytics aim to speed internal processing but do not reduce the number of urologic services requiring PA or the use of peer-to-peer reviews.
Hospital Care-Coordination Pilot
Aetna’s nurse-embedded program primarily affects inpatient transitions and has minimal relevance to outpatient specialty practices.
Impact on Independent Urology Practices
Modest Gains
- Fewer duplicate PAs for prostate cancer surveillance imaging.
- Auto-approval of select pharmacy benefits when tied to a medical PA.
Major Barriers Persist
- Surgery: Radical prostatectomy, cystectomy, nephrectomy, stone procedures, prosthetic surgeries, all still require full PA.
- Advanced Prostate Cancer: PSMA PET, lutetium-177 therapy, next-generation AR inhibitors tightly managed with frequent peer-to-peers.
- Radiation Oncology: SBRT, brachytherapy, and related technologies continue to undergo comprehensive review.
- ASC/Site-of-Care: No change in credentialing and utilization management.
- Administrative Burden: LUGPA practices report no reduction in staff hours or costs; many report an increase in PA volume in 2025.
LUGPA’s Prior Authorization Reform Priorities
To meaningfully reduce burden and improve timely access to care, LUGPA supports reforms that include:
- Gold-carding (exempting physicians with consistently high prior-authorization approval rates from needing future PAs for certain services or medications) for clinicians with ≥90% PA approval rates.
- Binding decision timelines:
- Urgent requests: 24–48 hours
- Standard requests: ≤5 business days
- Transparency: Reporting of denial rates, overturn rates, decision times, and clinical criteria.
- Prohibition of retroactive denials when an active PA exists.
- Modernized electronic PA systems with standardized documentation.
- Limits on peer-to-peer requirements, particularly for cancer and surgical care.
Conclusion
Aetna’s 2025 initiatives provide small efficiencies but do not address the underlying PA burden affecting independent urology practices. Most high-acuity and high-volume services remain subject to full review, and practices continue to experience delays, growing administrative strain, and unpredictable decision timelines. Systemwide, enforceable reforms—not voluntary pilots—are essential to ensure timely, patient-centered, and clinically appropriate urologic care.
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