Anthem, which offers commercial insurance plans in 14 states, said anesthesia needs vary and so should coverage. 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.
“The presence of anesthesia personnel is one of the key ingredients in the patient safety and effectiveness of cataract surgery today,” said Dr. David Glasser, an surgeon.
According to a statement from the company, “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 and patient-specific needs should be taken into consideration as well as potential risk of harm to individuals who are sedated during surgical procedures.” Medicare, the health care program for people age 65 and older, covers cataract surgery, including anesthesia services.
A cataract, typically related to aging, is caused by protein deposits on the lens of the eye that make it cloudy and can distort vision. During a cataract operation, the surgeon makes an incision in the surface of the eye with a laser or blade and then uses a tool to break up the clouded lens, pull it out and replace it with an artificial one.
Surgery is typically performed on an outpatient basis and takes less than an hour. Though drowsy while sedated, patients are generally conscious during the procedure and can hear what’s said to them and speak if necessary.
Eye surgeons often have an anesthesiologist or a nurse anesthetist present to administer intravenous drugs to help keep the patient relaxed and ensure they don’t move during the operation as well as monitor their vital signs and adjust medication as necessary.
Anthem’s new policy states that this type of monitored anesthesia care is medically necessary only if the patient is under 18 years old, or is unable to cooperate or communicate because of dementia or other medical conditions, can’t lie flat, has known problems with anesthesia, or if a complex surgery is anticipated.
Last year, the company announced it would no longer pay for emergency department visits it later determined were not emergencies. Then in September it said it would no longer pay for imaging tests like MRIs in many cases if patients got them at hospital-owned centers rather than independent imaging centers.
Last week, Modern Healthcare reported that the company said it was modifying its ER rule so that certain types of visits would always be paid for, including those by patients who are directed to the emergency department by their provider or have recently had surgery. Some safety experts said they were concerned about Anthem’s new policy, even for routine cataract surgeries.