Anthem MAC Anesthesia for Cataract Cases

California Clients
Anthem MAC Anesthesia for Cataract Cases

We have recently received news that Anthem has changed their policy in regard to the Medical
Necessity of MAC anesthesia for cataract cases.  Anthem states “Administration of moderate sedation,
monitored anesthesia care or general anesthesia for cataract surgery is considered medically necessary
for any one of the following reasons:

  • Children less than 18 years old
  • Individuals who are unable to cooperate or communicate (ex: dementia, acutely agitated, or movement disorder)
  • Individuals unable to lay flat (ex: severe back pain, congestive heart failure)
  • individuals who have failed or have contraindications to topical or regional anesthesia
  • Anticipation of prolonged or complex surgery

It is not medically necessary for all other indications.
To ensure payment on these accounts, we have two suggestions:

  1. Ask your surgeons to include anesthesia on the authorization when requesting the surgery authorization from Anthem
  2. Have the patient sign a Medical Necessity Waiver (copy can be supplied upon request)

a. This will inform them that you are a contracted provider but your services may be denied as “Not Medically Necessary” and they will be held responsible for the dollar amount you designate on the waiver

It is our understanding The California Medical Association, California Academy of Eye Physicians and Surgeons and the California Society of Anesthesiology will mobilize to fight this.  However, the policy was instituted with no formal notification and was adopted on December 27, 2017.

The average Anthem volume of cataract cases in 2017 for RCM clients was 5.33%.  If you would like to know the impact to your particular practice, feel free to contact us and we will go over those numbers with you.