Monitored Anesthesia Care in Cataract Surgery

Anthem BlueCross BlueShield recently announced guidance to deny coverage for monitored anesthesia care (MAC) for cataract surgery. They also sent notification to their providers that they don’t believe that MAC provided by anesthesia personnel is warranted in the vast majority of cataract procedures given the overall safety of the procedure, and they refer to only 1 article¹ published in a scientific journal in support of this decision.

I am the senior author of this article and wish to set the record straight, as they have misinterpreted our findings and made statements that are directly contrary to our conclusions and to those of Randall J. Olson, MD, the paper’s discussant.

Our paper states, “In 1,006 consecutive cataract surgery cases, intervention by anesthesia personnel was required in 376 (37.4%) of cases. No preoperative characteristics were found to be reliable predictors of the need for intervention.” Certain subgroups of patients were significantly more likely to need intervention, including those with systemic hypertension and pulmonary disease, and those under age 60. We concluded, “Because intervention is required in more than 1/3 of cataract surgery cases and the authors cannot reliably predict those patients at risk, monitored anesthesia care seems justified in cataract surgery with the patient under local anesthesia.”

These results may be tempered by the fact that more cases are now done under topical anesthesia than peribulbar anesthesia, and 19 years have elapsed since the study was performed. Nonetheless, until such time that there is scientific evidence to support claims to the contrary, we still believe that decisions regarding the advisability of MAC in cataract surgery should be made by the surgeon in consultation with the patient and family. How can the ophthalmic surgeon be expected to adequately monitor his or her patient while concentrating on performing intricate surgery? In the event of an intraoperative problem, anesthesia personnel are far better qualified to intervene than ophthalmologists are.

We do not recommend putting patients at risk for the potential cost savings.

Steven I. Rosenfeld, MD, FACS
Delray Beach, Fla.

___________________________

1 Rosenfeld SI et al. Ophthalmology. 1999;106(7):1256-1261.

From the editors: At time of press, the Academy’s advocacy team was continuing direct discussions with Anthem to secure immediate reversal of its guidance on monitored anesthesia during cataract surgery.