Anthem will no longer cover general anesthesia or Monitored Anesthesia Care (MAC) during cataract surgeries, claiming in their recently published clinical guidelines that in most instances it is not medically necessary.
The payer provided a few exceptions when anesthesia for cataract surgery would be covered, including the following circumstances:
- Children less than 18 years of age; or
- Individuals who are unable to cooperate or communicate (for example, dementia, acute agitation, or movement disorder); or
- Individuals who are unable to lie flat (for example, severe back pain, congestive heart failure); or
- Individuals who have failed or have contraindications to topical, local, regional, or moderate sedation anesthesia; or
- Anticipation of prolonged or complex surgery.
Citing the American Academy of Ophthalmology’s Preferred Practice Pattern for Cataract in the Adult Eye (2016), Anthem claimed “a variety of anesthesia techniques can be used during cataract surgery including local or regional anesthesia, and general anesthesia. While the preferred method of anesthesia is local or regional anesthesia, general anesthesia may be necessary depending on an individual’s medical, psychosocial, or surgical condition,” which they acknowledged in their highlighted exceptions.
The new guideline does not address minimal or moderate (conscious) sedation.
The American Society of Anesthesiologists (ASA) has asked Anthem to rescind the guideline, citing two key concerns:
- “There is no circumstance when it is considered acceptable for a person to experience emotional or psychological duress or untreated pain amenable to safe intervention while under a physician’s care, and
- “The decision as to the medical necessity of anesthesiology services for a patient is a medical judgment that must consider all patient factors, procedure requirements, potential risk and benefits, requirements or preferences of the physician performing the surgery/procedures, and competencies of the involved practitioners.”
According to Becker’s ASC Review, the Outpatient Ophthalmic Surgery Society also criticized Anthem’s new clinical clinical guideline, calling it a “threat to patient care, health and safety” and asking that it be rescinded.
“The guideline reflects a misguided view of the complexity of cataract surgery, the relative training and skill sets of the ophthalmic surgeon and anesthesia provider, and the unique characteristics and health status of the typical cataract patient,” said OOSS President Jeffrey Whiteman in a prepared statement.
This new clinical guideline is the most recent of a string of recent policy changes by Anthem that have hospital and physician groups crying foul. According to an article by FierceHealthcare, Anthem representatives said, “We have been and will continue to have a dialog with our providers and medical societies to discuss any of our programs.”
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