Insurance provider under fire for changing coverage of monitored anesthesia

Anthem’s decision is not well accepted in ophthalmic community; surgeons call for rescindment.

Anthem Blue Cross and Blue Shield is receiving a thunderclap of negative feedback for a recent decision it made to eliminate monitored anesthesia coverage involving cataract surgery.
Cataract surgeons with Anthem-insured patients are facing decreased coverage per surgery for monitored anesthesia: the insurer is still covering for topical, regional and local anesthesia.
Anthem has determined that the “administration of monitored anesthesia care (MAC) or general anesthesia for cataract surgery is considered not medically necessary” under most circumstances, and therefore will not reimburse for these services. Some exceptions include children under 18 years of age and individuals, such as those with dementia, who either cannot cooperate, communicate and/or lie flat. 
This decision is now under review, at least in California, because of the feedback, according to Anthem and others.
Whether topical or IV anesthesia, the presence of a monitoring anesthetist is critical, says Larry E. Patterson, MD. “We are looking through a microscope at the entire procedure,” says Dr. Patterson, Ophthalmology Management’s chief medical editor. “We can’t possibly monitor patients and their vital signs while operating. Even if we could, we are operating and therefore are not in a position to take action.” 
In response to OM regarding its decision, Anthem replied, “Anthem’s Medical Policy and Technology Assessment Committee, a majority of whom are external physicians, reviewed the available evidence addressing the use of general anesthesia and monitored anesthesia care for cataract surgery. According to the literature reviewed, there is no one definitive approach regarding the use of anesthesia for cataract surgery …   Anthem’s guideline allows for general anesthesia and monitored anesthesia care for cataract surgery when clinical indications support that they are medically necessary and provides coverage for other forms of anesthesia, including intravenous moderate sedation, without the need for review.”
Anthem, an independent licensee of the Blue Cross and Blue Shield Association, offers commercial insurance plans in 14 states and specialty plans in others.
Those opposed 
The ophthalmic world has called on Anthem to reconsider its position. According to the AAO’s website, leadership has told Anthem the guidance should be eliminated. “No one should be expected to undergo eye surgery without an anesthesia provider on-hand,” the website says. 
Not monitoring patients with anesthesia providers is a bad move, says Dr. Patterson’s son, Michael Patterson, DO. “No chance can I be sterile and push medications for my patients at the same time and then operate.”
To operate without anesthesia is not an option, Michael Patterson says, as “it is clearly the standard of care at this time.”
Other ophthalmic organizations have not been idle. Outpatient Ophthalmic Surgery Society (OOSS) President Jeffrey Whitman, MD, said in a letter to Anthem, “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.”
ASCRS’ President Bonnie An Henderson, MD, protested the change, noting that patients undergoing cataract surgery are generally elderly with comorbidities and significant medical issues; there is also the difficulty in predicting the level of sedation preoperatively.1
Until the issue is resolved, the AAO has urged ophthalmologists to “refrain from charging patients for monitored services.” Kevin Corcoran, president of Corcoran Consulting Group, said, “In similar situations, we have seen that some payers revised their policies and retroactively paid claims that would otherwise have been denied.”
While Anthem has caused a stir with its policy on anesthesia for cataract surgery, the insurer is not indifferent to the medical community and its protests, as evidenced by its pronouncement late last month to retract its decision to slash modifier 25 reimbursements.2  The strong clinical arguments supporting monitored anesthesia at the time of cataract surgery may yet persuade Anthem to recant that recent policy. OM

1.  Anthem BC/BS of California to Reconsider Anesthesia for Cataract Coverage Policy Following ASCRS and Ophthalmic Community Advocacy.
2.  Stewart A. Anthem halts controversial modifier 25 reimbursement policy – 4 insights.