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ASAP to the ASA

Dear Drs. Lema and Cohen,

The American Society of Anesthesiologists (ASA) recently supplied Aetna with a list of arbitrary ICD codes that were used to create a new MAC anesthesia policy. We are very disappointed in what we perceive to be a myopic and wholly inappropriate response to Aetna’s request.

The ASA medical necessity statement acknowledges that the decision to use anesthesiology services should be made by the treating physician in consultation with the patient. Anesthesiology neither cures nor treats medical disease. It is used to provide a safe, secure and comfortable patient experience. In the case of cataract surgery where sometimes no medication is given, anesthesiologists are asked to participate to ensure comfort and safety through other means. In the case of labor epidurals, the intrinsic value of pain relief for parturients overrides the paucity of conclusive outcome studies demonstrating any certain impact on the health status of the mother or new child.

The list of ICD-codes that the ASA supplied is arbitrary. None of the codes can be linked to outcome studies. To suggest and accept the premise in Aetna’s new policy that a screening colonoscopy patient who is age 64 may benefit from anesthesia less than one who is 66 is absurd. Morever, such policy can also be viewed as discriminatory against patients based on their age or medical state. Furthermore, there is no data that a patient with mild asthma or hypertension can benefit from anesthesia more or less than a healthier or sicker patient. Anesthesia care should be strictly a decision made by and between physicians and their patients. If similar policy changes were imminent surrounding the indications for labor epidurals or acute pain blocks a far different response from the ASA would be likely. As hospital-based anesthesiologists practicing is one specific part of the country, perhaps ASA committee members Dr. Norman Cohen and Dr. Alex Hannenberg, as well as others involved in providing these codes, may come from a different perspective than those who practice in ambulatory environments.

What are the implications of the ASA's decision to engage Aetna on their terms, rather than sticking to the ASA latest medical necessity statement? It legitimizes a policy that can, and likely will be applied to other procedures where MAC is common such as knee arthroscopy, foot surgery, hand surgery, breast biopsy and less invasive urological, ENT and ophthalmology cases. Once the ASA's tactical decision rolls down the slippery slope, those who practice in surgery centers and out-patient hospitals--as well as those very facilities themselves-- will feel aggrieved if not alienated. This engagement of Aetna obfuscates the real issue--medical cost. It is our view that the ASA could have reacted to Aetna by telling them that this is a management issue for which any managed care organization has full accountability and responsibility. To instead provide a list of codes may partially abrogate Aetna of their charge. Perhaps the real issue is high medical loss ratios stemming from out-of-network providers charging outrageous fees and engaging in revenue management mischief. If so, it is still incumbent upon Aetna, not ASA, to manage their network and particularly to police their out of network costs. Denying patients, surgeons, and facilities anesthesia care based on a list of arbitrary ICD codes is a broad, if not sloppy approach. The ASA has historically refrained from directly remarking to managed care organizations on medical necessity issues. It is at a minimum duplicitous that the ASA helps managed care organizations manage their costs through efforts that ultimately devalue the role of Anesthesiologists in patient care and in the medical environment.

The ASA's position is not aligned with those who care for patients undergoing less intensive procedures involving MAC. Our intention is to resign from the ASA and direct our dues and the dues of our group to organizations who approach these issues from a different mindset.


Robert Goldstein, M.D.



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