A major health insurer wants to deny coverage of anesthesiology services during cataract surgery, saying the surgeon can handle sedation and emulsification on his own.

Think your eye docs would mind much if they had to administer IV sedatives and look up from the microscope during the case to monitor vital signs? Of course they would (as would your patients!), but they might have to if Anthem delivers on its promise to eliminate coverage for an anesthesiologist or a nurse anesthetist during what it calls "routine" cataract surgeries. "You want your ophthalmologist focusing only on the surgery at hand and not the patient's anesthesia issues," says Steven Gayer, MD, MBA, chief of surgery and anesthesia at Bascom Palmer Eye Institute in Miami, Fla. "I would hate to be the surgeon who has a case of a vocal local: trying to talk a patient down with no one in the room to help."

In a clinical guideline (osmag.net/fR2uCB) released in February, Anthem states that ophthalmologists can administer and monitor sedation without jeopardizing patient safety. The guideline also says that monitored anesthesia care is medically necessary only under certain circumstances: if the patient is younger than 18 years old, or is unable to cooperate or communicate because of dementia or other medical conditions, can't lie flat, has not tolerated conscious sedation, or if a complex surgery is anticipated. For all other cases, Anthem considers MAC or general anesthesia not medically necessary.

Organized opposition

As you might imagine, the cataract and anesthesia communities are up in arms, calling on Anthem to rescind the policy before it's enacted (no date has been set and Anthem did not respond to a call for comment). All the major medical societies in ophthalmology and anesthesia have sent letters of protest to Anthem's medical director.

This is not the first time an insurer has tried to deny coverage of anesthesiology services during cataract surgery. Noridian introduced a similar guideline in 2002.

"We fought it and kicked their you-know-whats," says Dan Simonson, CRNA, the former manager and chief CRNA of an eye center in Spokane, Wash.

How did they do it? By presenting evidence-based objections to the carrier's medical director — the person responsible for making these guidelines. "When we showed him an article that stated that 1 out of every 100 patients getting cataract surgery would experience an adverse event that needed intervention by an anesthetist, he backed off," says Mr. Simonson.

And that's just what the organizations that represent anesthetists and ophthalmologists are hoping happens this time.

But what evidence are they citing now? Anthem listed some peer-reviewed articles at the end of the guideline that they say supports their policy. One of those papers, however, seems to argue against their guideline. The paper looked at more than 1,000 cataract surgeries and found that in more than one-third of them, the anesthetist had to intervene because the patient was having an adverse event. Since there wasn't a reliable way to predict which patients were at risk for these events, "monitored anesthesia care seems justified in cataract surgery with the patient under local anesthesia."

"It's remarkable that they misinterpreted the results of that paper," says David B. Glasser, MD, secretary for federal affairs of the American Academy of Ophthalmology. He points out that even a minor intervention could turn into a major one if the surgeon has to spend time finding the proper person to handle it. "While there are things the surgeons may do by themselves," adds Dr. Glasser, "that's not something an ophthalmologist can do while also working on a patient's eye."

Ophthalmologist Hunter Newsom, MD, agrees. "Just last week, I had 40 cases in one day, 30 another. I know a certain percentage of patients are going to need something beyond the normal. If something starts to go wrong and I don't have an anesthetist there to handle it, it would mean I went in knowingly unprepared," says Dr. Newsom, who owns 3 Florida eye surgery centers. "I have zero interest in not having anesthesia present during my cataract surgeries."

A dangerous precedent

This policy would only affect patients and providers in the 14 states where Anthem provides services — for now. "If Anthem implements this guideline, it could pave the way for other third-party providers to do the same," says Bruce Weiner, DNP, CRNA, president of the American Association of Nurse Anesthetists.

And he's justified in pointing this out, according to Mr. Simonson. Back when Noridian tried this for cataract surgery, they also introduced a guideline that said they wouldn't pay for MAC for colonoscopies.

"The endoscopists didn't fight them because many of them weren't using CRNAs to provide anesthesia," says Mr. Simonson. Wellpoint and Humana soon followed Noridian's lead. A few years later, Aetna tried to introduce a similar guideline, but it was rescinded after GI doctors and their societies spoke out against it.

Anthem revised its guideline after its release to be specific to anesthesia care and removed mention of moderate sedation, according to an ASA press release. But the "revision does not address the fundamental flaw of the guideline," the ASA says in its letter to Anthem that highlights a few of the ways this guideline disrupts patient care. For example, most patients wouldn't be able to tolerate the placement of a needle for a retrobulbar block without anesthesia care.

"The block takes 8 seconds, but they're a crucial 8 seconds," says James D. Grant, MD, president of the American Society of Anesthesiologists. "If someone jerks the wrong way during the block, the eyeball could get damaged."

Many are hoping the epic team-up between nurse anesthetists, physician anesthetists and ophthalmology organizations convinced Anthem to put the guideline in an indefinite holding pattern.

"You know, nurse and physician anesthetists are rarely on the same side — except when it comes to patient safety. So you know this [guideline] is not a good idea," says Jay Horowitz, BSN, CRNA, ARNP, of Sarasota, Fla. OSM