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The Anthem Situation
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Non-Coverage of Monitored Anesthesia


In January 2018, insurance provider Anthem posted new guidance positing that monitored anesthesia during cataract surgery is not medically necessary and suggested it will no longer cover these anesthesia services.



Anthem's guidance indicates that cataract surgery does not require monitored anesthesia care except in very specific, “medically necessary” situations. The document indicates that local or regional anesthesia should suffice. 

AAO leadership, including the health policy committee and staff, continue to directly communicate with Anthem’s leadership in an effort to eliminate this guidance. 

Anthem insists it intended this document only as guidance, not to determine payment or coverage decisions. Anthem claims they have denied no services.

Recent news articles

Kaiser Health News
The Daily Mail
Becker’s Hospital Review
Ocular Surgery News

AAO is urging members to forward de-identified copies of any denials of anesthesia claims based on the guidance to

What AAO Is Saying to Anthem

The literature does not support the concept that monitored anesthesia care is unnecessary for routine cataract surgery. The highest standard of care and the level of sedation most commonly used includes the presence of a CRNA or anesthesiologist. Anthem needs to present evidence for widespread adoption and safety of unmonitored care for cataract surgery before it suggests lesser levels are acceptable.

Complications will occur that require an anesthesia provider be available. From treatment of hypertension, respiratory arrest, cardiac complications to anxiety, non-cooperation and surgical complications, an anesthesia provider must be available to treat these conditions. 

Complications can also occur at any time in a case requiring more extensive anesthesia. Ophthalmologists are occupied elsewhere working inside the eye and are not trained to treat these emergency conditions. To maintain and ensure patient safety, it is imperative to have an anesthesia provider in the OR. 

David Glasser, MD, the Academy's secretary for federal affairs, served as Academy spokesman for these interviews: "The presence of anesthesia personnel is one of the key ingredients in the patient safety and effectiveness of cataract surgery today," Dr. Glasser told Kaiser Health News. "An ophthalmologist cannot administer conscious sedation and monitor the patient and do cataract surgery at the same time."


AAO Talking Points

  • Cataract surgery is very common — Medicare reimbursed 1.7 million cases in 2016 —but also very intense. It requires the surgeon’s full attention s/he operates on a very delicate organ.
  • Three things happen simultaneously during this surgery, all of which a single surgeon cannot perform at once: administration of sedation; monitoring the patient and performance of the cataract surgery.
  • Cataract surgery commonly uses monitored anesthesia to improve patient comfort and safety.
  • Someone specifically trained and licensed to monitor sedated patients must be present as the surgeon concentrates 100 percent on the eye surgery.
  • The person monitoring the patient should be an anesthesiologist or CRNA.
    Typically 9 percent of patients having cataract surgery require the intervention of an anesthesiologist or CRNA for more than simple sedative administration to ensure a routine, uncomplicated case (i.e. additional medication for comfort, maintaining a clear airway, etc.)
  • If no anesthesia personnel are present in the room, a delay in treatment of a routine problem could turn it into a serious complication.
  • Patients need to be at a level of sedation in which they are comfortable but able to follow surgeons’ instructions.
  • Surgeons are not in a position to know when patients need more or less sedation or stimulation. Likewise, during surgery, surgeons are not in a position to adjust patients’ level of sedation.
    The American Academy of Ophthalmology’s Preferred Practice Pattern® guidelines clearly state that anesthesia personnel should be present when the patient receives sedation significant enough to require intravenous access.


Click here to download a talking points one-pager 

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