Anthem, Inc. (“Anthem”) is one of the largest health benefits companies in the United States. Anthem is an independent licensee of the Blue Cross and Blue Shield Association serving members in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin; and specialty plan members in other states.
On February 1, 2018, Anthem published its “Clinical UM Guideline” entitled “Monitored Anesthesia Care and General Anesthesia for Cataract Surgery” in which is advised that it would not pay for the administration of monitored anesthesia care (“MAC”) or general anesthesia for cataract surgery under many circumstances because it “is considered not medically necessary.”
The Guideline states, in part:
Administration of monitored anesthesia care (MAC) or general anesthesia for cataract surgery is considered medically necessary for any one of the following:
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.
Not Medically Necessary:
Administration of monitored anesthesia care (MAC) or general anesthesia for cataract surgery is considered not medically necessary for all other indications and when criteria above are not met.
The Guideline further states: “Cataract is a clouding of the eye’s lens. According to the Centers for Disease Control and Prevention (CDC), cataracts are the leading cause of vision loss in the United States affecting an estimated 20.5 million Americans over the age of 40 (CDC, 2015). Treatment of cataracts can include eyeglasses and brighter lighting. Definitive therapy includes surgery which removes and replaces the cloudy lens with an artificial lens … Monitored Anesthesia Care (MAC) was developed in response to the shift to providing more surgical and diagnostic services in an ambulatory, outpatient or office setting without the use of the traditional general anesthetic. Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a combination of local, regional and certain consciousness altering drugs. This type of anesthesia is referred to as MAC if directly provided by anesthesia personnel. Based on the American Society of Anesthesiologists (ASA) standards for monitoring, MAC should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists [CRNA]). These individuals must be continuously present to monitor and provide anesthesia care.”
The Guideline concludes: “there is no one definitive approach to anesthesia for cataract surgery. The use of anesthesia during procedures should be balanced with the potential risk of harm to those individuals who are sedated during pain procedures. This guideline does not address minimal or moderate (conscious) sedation, which is typically administered intravenously. It is a guideline for when MAC and general anesthesia, which require the service of an anesthesiologist, CRNA, or other certified personnel is appropriate and medically necessary as outlined in the clinical indications above.”
So, What Does The Guideline Mean For Patients And Their Safety?
Kaiser Health News (“KHN”) quotes an ophthalmologist who is secretary for federal affairs at the American Academy of Ophthalmology: “The presence of anesthesia personnel is one of the key ingredients in the patient safety and effectiveness of cataract surgery today. An ophthalmologist cannot administer conscious sedation and monitor the patient and do cataract surgery at the same time.”
KHN quotes an ophthalmologist who is the president-elect of the California Medical Association: “I wouldn’t even consider doing a cataract surgery without an anesthesiologist or nurse anesthetist in the room. If you’re working inside the eye it’s a very confined space, and if the patient gets agitated and starts moving around you have to get the equipment out of the eye very quickly.”
KHN reports: “If you need cataract surgery, your eye surgeon may have to do double duty as your anesthetist under a new policy by health insurer Anthem. In a clinical guideline released this month, the company said it’s not medically necessary to have an anesthesiologist or nurse anesthetist on hand to administer and monitor sedation in most cases. Some ophthalmologists and anesthesiologists say the policy jeopardizes patient safety, and they are calling on Anthem to rescind it.”
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