ASA Calls on Anthem to Rescind Its New Policy on Anesthesia for Cataract Surgery

Anthem recently released a new Clinical Guideline (CG-MED-60: Monitored Anesthesia Care (MAC) and General Anesthesia for Cataract Surgery) that significantly narrows the instances under which it would consider anesthesia care to be medically necessary for patients undergoing cataract surgery. According to this new guideline, anesthesia (either general or Monitored Anesthesia Care (MAC)) would be considered medically necessary only if any of the following criteria are met:

• Children less than 18 years of age; or
• Individuals who are unable to cooperate or communicate (for example, dementia, acutely agitated, 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 or regional anesthesia; or
• Anticipation of prolonged or complex surgery

Anthem revised its guideline after initial release to be specific to anesthesia care and removed the original version’s inclusion of moderate sedation. That revision does not address the fundamental issues of the guideline.

The American Society of Anesthesiologists sent a letter to Anthem calling on the company to fully rescind the guideline. We describe our opposition to the policy, specifically noting that:

• 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.

ASA will post updates as more information becomes available. Within California, the California Society of Anesthesiologists (CSA) is leading a comprehensive effort to address this harmful proposed policy.

Read Anthem CM-MED-60 here.
Read the ASA letter here.