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Anesthesia Services for Cataract Surgery ‘Not Medically Necessary’: Insurer Anthem
February 26, 2018
Managed healthcare organization Anthem has released a clinical guideline stating that monitored anesthesia care and general anesthesia are not medically necessary for the majority of patients undergoing cataract surgery. We summarize the healthcare community’s response, including efforts by the American Academy of Ophthalmologists to rescind the guideline.
“Someone cutting into my eye isn’t routine for me.”
These words from Leah Binder of patient safety organization Leapfrog Group capture the tenor of the response to a new clinical guideline from insurance company Anthem, Inc., proclaiming monitored anesthesia care (MAC) and general anesthesia “not medically necessary” for the majority of patients who undergo cataract surgery.
In essence, the guideline, released this month, asks eye surgeons to assume responsibility themselves for topical, local or regional anesthesia or conscious sedation for all cataract patients other than:
- 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.
The move triggered vigorous opposition from the medical community, notably the American Academy of Ophthalmology (AAO), which describes the measure as “anti-patient non-coverage” and a maneuver to cut costs at the expense of patient safety and clinical quality.
“Ophthalmologists cannot administer anesthesia, monitor a patient and do cataract surgery at the same time. It is not physically possible,” AAO spokesman David Glasser, MD, stated in an interview. “The presence of anesthesia personnel in and throughout the procedure is one of the key ingredients contributing to the excellent safety record of cataract surgeries.” Cataract surgery has a success rate of 98 percent, according to AllAboutVision.com.
The California Academy of Eye Physicians and Surgeons and the California Society of Anesthesiologists (CSA) have sent letters to Anthem asking them to immediately rescind the policy. The California Medical Association has issued complaints to the California Department of Managed Health Care (DMHC) and the California Department of Insurance.
“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,” wrote Karen S. Sibert, MD, FASA, president of the CSA, in the Anthem letter.
Today, cataracts affect more than 22 million Americans age 40 and older, and more than 30 million Americans are expected to have cataracts by 2020, according to Prevent Blindness America. Though most cataract surgery patients are over the age of 65, and many are living with significant comorbidities that could put them at risk for anesthesia complications, most of these patients would no longer meet Anthem’s criteria for medical necessity. The AAO and other groups have accused the company of “cherry picking” medical evidence to justify the guideline.
The policy could have large-scale impact. An estimated three million Americans have cataract surgery each year, according to the Statistic Brain Research Institute, and that number is expected to continue to mushroom rapidly as the population ages. As the largest for-profit managed healthcare company of Blue Cross Blue Shield, Anthem insures 73 million Americans.
A 2016 study in the Journal of Cataract and Refractive Surgery offers a striking example of the value of an anesthesiologist’s presence during cataract cases. The study found a significant association between ASA Physical Status and cataract surgery outcomes in U.S. veterans, concluding that “ASA classification could be an important predictor of vision-related quality of life (VRQL) and visual outcomes.” ASA Physical Status was associated with increased risk for two serious and costly unanticipated events—clinically significant macular edema and hospital readmission—providing yet another illustration of the specialty’s leading role in patient safety.
Opponents fear the Anthem policy could signal a “slippery slope” of removing coverage for other vital healthcare services that would jeopardize the quality and safety of care. ABC is following the situation and will provide updates as new developments arise.
With best wishes,
President and CEO