Health insurer Anthem, Inc. published a policy change on December 27, 2017 that leaves medical providers concerned about patient safety. The policy, “CG-MED-60 Anesthesia for Cataract Surgery,” restricts the use of monitored anesthesia care (MAC) and general anesthesia for cataract surgery with few exceptions for medical necessity. Anthem patients will have to pay out of pocket if they desire to have any form of intravenous anesthesia.
What are the exceptions? Anthem’s published guidelines only consider MAC or general anesthesia medically necessary for any one of the following:
- Children less than 18 years of age; or
- Individuals who are unable to cooperate or communicate; or
- Individuals who are unable to lie flat; or
- Individuals who have failed or have contraindications to topical or regional anesthesia; or
- Anticipation of prolonged or complex surgery.
Anthem amended their policy on February 1, 2018 to state that the policy does not exclude “moderate sedation”. However, “moderate sedation” would be managed by the surgeon. Documents from the American Association of Ophthalmology (AAO) describe a surgeon should not divide time between both tasks due to the risks with performing cataract surgery which requires very precise work. When sedation is anticipated a qualified anesthesia provider would be required, and the activity would become “monitored anesthesia care,” which is excluded in the policy outside of the narrow exceptions.
What are the concerns? In a letter to the insurer, President Karen S. Sibert, MD, FASA with the California Society of Anesthesiologists (CSA) writes, “If Anthem restricts payment for MAC services, thousands of patients either will have to pay for the service themselves or will have to undergo surgery under suboptimal conditions. This guideline seems especially harsh toward fragile elderly patients, many of whom have other coexisting illnesses that complicate the use of sedation.”
Anthem is the first major insurer to restrict the use of MAC or general anesthesia for cataract surgery. As a major insurer in many states (California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin), there is concern other insurers will soon follow.
What should you do? Anesthesia providers should consider documenting any one of the five scenarios where medically necessary conditions exist in the event we see other insurers follow suit. Additionally, anesthesia providers are in a position to add value to the care patients receive. Work with state and national level organizations or submit your own letter to Anthem on behalf of your independent practice to voice your concerns surrounding safety and care of patients.
abeo will continue to bring updates like this to the anesthesia community and our clients.
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