Anthem gets flak for anesthesia coverage policy

anthem
Doctor groups in California say Anthem's coverage policy for anesthesia during eye surgery "falls below the standard of care." (Matthew Hurst / CC BY-SA 2.0 / https://www.flickr.com/photos/skewgee/2463077387)

Doctors in California are raising the alarm over a recent policy change from Anthem that they say could harm patients undergoing cataract surgery.

The policy categorizes monitored anesthesia care as “not medically necessary” during routine cataract surgery, according to the California Academy of Eye Physicians and Surgeons, the California Society of Anesthesiologists and the California Medical Association.

However, the groups contend that sedation is frequently needed to allow the patient to relax and avoid movement that could have catastrophic consequences—including blindness.

Anthem amended the policy on Feb. 1 to clarify that it doesn’t intend to exclude “moderate sedation” from coverage, but it also said such sedation would have to be managed by the surgeon, according to the provider groups. But that’s still problematic, they argued, because the procedure is very precise work, and it’s not a good idea to divide a surgeon’s attention while doing it.

The California providers say they’ve sent letters to Anthem asking the insurer to rescind the policy and filed complaints with the California Department of Managed Health Care and the California Department of Insurance.

"Anthem's newest policy change falls below the standard of care, and it follows a disturbing pattern of putting patients at risk to make a profit," David H. Aizuss, M.D., an ophthalmologist and president-elect of the California Medical Association, said in the release.

Anthem, however, told FierceHealthcare it made its decision based on a review of the available evidence and concluded that "there is no one definitive approach regarding the use of anesthesia for cataract surgery."

The insurer said it thus designed its guideline to allow for general anesthesia and monitored anesthesia care for cataract surgery "when clinical indications support that they are medically necessary" and that it provides coverage for other forms of anesthesia without limitations or the need for any kind of review.
 
"We have been and will continue to have a dialog with our providers and medical societies regarding their concerns," Anthem added.

The criticism from California doctors comes as the insurer is also facing pushback from providers on some of its other recent policy shifts.

Doctor groups say one Anthem policy—which denies coverage for visits to the emergency room for injuries or conditions that aren’t actually emergencies—can force patients to avoid treatment or second-guess their symptoms. Providers have also taken issue with Anthem’s new policy aimed at steering patients toward freestanding imaging centers, rather than hospitals, for services like CT scans or MRIs.