Download Spring 2009 - Iowa Society of Anesthesiologists

ISA UPDATE
NEWS FOR THE IOWA SOCIETY OF ANESTHESIOLOGISTS
President’s Message
Spring 2009 Issue
changing our administrative staff to
DMS we have been able to
reinvigorate our web presence,
improve the annual spring meeting,
resurrect the fall meeting and build
new relationships with our state
legislators and the governor.
Presently,
our
state
PAC
contributions are at an all-time high;
something that has facilitated our
legislative success. This trend must
continue.
I’d like to think that I met the goals of
my administration and in the process
enhanced the safety of Iowans and
the professional security of ISA
membership. Over the preceding
two years we have successfully
defeated a cut to our Medicaid
reimbursement
and
actually
garnered
a
1.5%
increase.
Cumulatively, this preserved in
excess of $3 million of revenue for
our membership. We have actively
fought against the CRNA practice of
interventional pain management and
at this time are on the brink of
putting this issue to rest in Iowa. By
As I pass the torch to Frank Cassady,
Jr., M.D., our new ISA president, I am
assured that our society is in good
hands. Frank and I have enjoyed an
excellent working relationship and
have together implemented the
successes of these past two years.
You can expect more of the same
during his term!
Despite steep declines in state tax
revenues, we are happy to report
that there will be no cut in Iowa’s
Medicaid reimbursement. This is in
part thanks to substantial federal
funds earmarked for this purpose.
ISA officers and officials have also
maintained an ongoing dialog this
year with legislative leaders.
We will continue to watch this issue
closely and fight against any
disproportionate decrease in fees to
anesthesia providers.
President
Joseph F. Cassady, Jr., MD
West Des Moines
President-Elect
Douglas G. Merrill, MD
Iowa City
It is with relief and melancholy that I
write my last president’s message.
Looking back, it has been an active
and productive two years. I want to
thank everyone that has made my
term in office such a success;
especially: my family and partners
who gave me the time to serve, the
executive committee and officers
who provided good counsel and the
administrative staff who’ve kept our
society running smoothly.
Iowa Legislative Update
Officers
Secretary/Treasurer
Sherif H. Tewfik, MD
Grimes
Immediate Past President
Patrick H. Allaire, MD
Ames
District Director
John R. Moyers, MD
Iowa City
Asst. District Director
James L. Becker, MD
Waukee
Patrick Allaire, MD
ISA President
In April, the Iowa Board of
Medicine (IBM) ruled that chronic
interventional pain management is
indeed the practice of medicine.
Attached, find a draft copy of this
ruling. This ruling will set
precedent and challenge any
finding by the Board of Nursing
(BON) that CRNAs are qualified to
perform these procedures. The
IBM finding is critical to any
legislative or judicial challenge
brought by the CRNAs; as it is
unlikely that the courts or our
1
legislators will go against the
finding of the IBM.
ISA has been intensely involved in
shepherding this ruling through the
Board of Medicine. A special
thanks goes out to Rick
Rosenquist, M.D., Professor, U of I,
for his counsel and expert
testimony at the IBM hearings.
ISA PAC
ISA Spring Meeting
ISA PAC distributed in excess of
$24,000 to 47 state legislators
during the past year. These funds
are critical to maintaining and
enhancing
our
legislators’
awareness of our issues at the
state capital. Presently, we have
about $11,000 in our PAC coffers.
It is vital that each and every ISA
member make an annual PAC
contribution.
The ISA spring meeting, held on
April 4, at the Hotel Fort Des
Moines was a huge success. A
record number of both attendees
and vendors were present. We
were treated to world class
lectures by Drs. Joy Hawkins,
Randy Clark and Mark Warner. Dr.
Warner’s participation represented
the third consecutive year that an
ASA Vice President has attended
our meeting.
Awards were
presented to Dr. Trish Hoffman,
outgoing IMS president and Dr.
Jim Becker, Immediate Past-Chair
of the ASA PAC Board of Directors,
for their contributions to the
anesthesia community.
Considering the successes ISA
has had in the past year at
preserving and enhancing your
incomes and protecting the
specialty of anesthesiology from
unqualified
interlopers…the
decision to make a contribution
should be easy!! Enclosed, find a
list of ISA-PAC donors and a
contribution form.
Mail yours
today, so you don’t have to feel
guilty the rest of the year.
ISA Officer Changes
Congratulations to the ISA officers
newly elected at the spring
meeting. Dr. Doug Merrill, U of I,
became president-elect and Dr.
Sherif Tewfik, Des Moines, was
elected secretary-treasurer. Your
ISA delegates and district directors
remain unchanged. Thank-you to
these excellent candidates for their
willingness to serve in this
volunteer capacity.
Following the annual business
meeting (minutes attached), the
ISA PAC cocktail reception was
very well attended and will be
continued at future meetings. Take
this opportunity to mark your
calendars for our fall legislative
update to be held in Iowa City on
Sept. 14. Also, next years’ spring
meeting will be held in West Des
Moines at the Holiday Inn and
Suites on April, 10, 2010. This
property is easily accessible (only
three blocks) from I-35 in West Des
Moines and is close to the Jordan
Creek Mall. Note that the venue is
changed due to renovations that
will be ongoing at the Hotel Fort
Des Moines. Please make plans to
attend and encourage your
practice partners to do the same.
Dr. Mark Warner, First Vice President
of the ASA, presented a session
focusing on Positioning Problems.
Wellmark Denies Anesthesia Claims for GI
Endoscopy
In its recently published rules for participation, to take effect July 1, 2009,
Wellmark has decided to deny anesthesia claims submitted for GI endoscopy,
with only a few exceptions (see attached). This ruling has created an outcry
from the anesthesia community. ISA opposes any third party intervention in the
prescriptive decision making between patient and physician. For this reason,
the ISA’s and ASA’s Presidents recently contacted Wellmark policymakers to
express compelling concerns regarding public safety implications as well as
Wellmark’s future to consider the right of Iowans to choose their own
healthcare. Individual ISA members may also contact Wellmark directly to urge
recision of the policy on these grounds.
Dues Increase
The fiscal realities of running an organization with multiple active legislative and professional issues requires
that from time to time dues are adjusted to cover the cost of these battles. The last time a dues increase was
sought was six years ago. In that time, we have enjoyed much success in the legislative arena, but at a
significant financial cost. For the last three years, we have run deficits and drawn from our reserves to cover
these costs (to the tune of $70,000). The board of directors is predicting continued deficits in the foreseeable
future if we do not adjust our dues.
Therefore, a $100 annual increase was sought and granted from the house of delegates at our annual meeting
in April. Your dues will therefore increase from $300 to $400 beginning in January, 2010. A paltry sum
considering that in 2007-08 the efforts of ISA and ASA enhanced the gross income of every anesthesiologist in
the state by more than $28,000.
2
DRAFT POLICY * DRAFT POLICY * DRAFT POLICY * DRAFT POLICY
The Board will discuss the policy statement and receive public comment about
it on May 21. Written comments for the board are due by April 24 and should
be mailed to Board Executive Director Mark Bowden, 400 S.W. Eighth Street,
Suite C, Des Moines, IA 50309 or e-mailed to [email protected]
Iowa Board of Medicine
Policy on Chronic Interventional Pain Management
Approved ___________
Definition
Chronic interventional pain management, as defined by the National Uniform Claims
Committee, is the diagnosis and treatment of pain-related disorders primarily with the
application of interventional techniques in managing subacute, chronic, persistent, and
intractable pain.1 Interventional pain techniques include percutaneous (through the skin) needle
placement. Drugs are then placed in targeted areas, nerves are ablated (excised or amputated), or
certain surgical procedures are performed. By way of example, procedures often involve
injection of steroids, analgesics, and anesthetics and include: lumbar, thoracic, and cervical spine
injections, intra-articular injection, intrathecal injections, epidural injections (both regular and
transforaminal), facet injections, discography, vertebroplasty, kyphoplasty, nerve destruction,
occipital nerve blocks, and lumbar sympathetic blocks. Interventional pain management may
also include the use of fluoroscopy.
Diagnosis and Treatment
Chronic interventional pain management involves interactive procedures in which the physician
is called upon to make continuing adjustments, noting that it is not the procedures themselves,
but it’s the “the purpose and manner in which such procedures are utilized” that demand the
ongoing application of direct and immediate medical judgment that constitutes the practice of
medicine. These procedures are used to assess the cause of a patient’s chronic pain, as a
therapeutic modality of treatment, and as a basis on which to recommend additional treatment,
including the need for surgical intervention and repeated or additional treatments. Often times
the pain physician will perform a different chronic interventional pain management procedure
than prescribed by the referring physician based on the pathophysiology of the patient and the
determination that a patient would be unable to withstand the prescribed procedure. In order to
practice competent chronic interventional pain management the pain physician must understand
the particular history of the patient, which includes a complete neurological, musculoskeletal and
psychological assessment, as well as review of the available diagnostic studies (both preprocedure images and those obtained during the actual performance of the procedure). Only then
can the pain physician develop a proper treatment plan which may or may not differ from the
1
Manchikanti, L. Medicare in interventional pain management: A critical analysis. Pain Physician. 2006;9: 171-197.
referring physician’s order.2 Chronic interventional pain management requires constant medical
diagnosis and judgment.
Risks
Interventional pain medicine carries serious risks: infections, brain damage, paralysis, or, even
death.3 The assessment of risks of invasive procedures must always be taken into account. The
performance of a “simple” epidural steroid injection, for example, for a herniated disk may be
associated with a multitude of side effects and complications including weight gain, immune
system suppression, spinal headache, nerve damage or even paralysis.4 Issues of concomitant
administration of anticoagulants and the appropriate management of these when performing
spinal or perispinal injections remains a paramount concern as well. Complications associated
with performing these procedures without proper training arise not only from the procedures
themselves, but from mismanagement of the patient as well.5 Allied health care practitioners,
including certified registered nurse anesthetists, and others, do not possess the medical training
or, therefore, the requisite knowledge or equivalent skills to perform the above in a safe and
competent manner.
Chronic interventional pain management constitutes the practice of medicine.
The practice of chronic interventional pain medicine has been established as a separate and
distinguished subspecialty of medicine in medical schools and in medical residencies and
fellowships throughout the United States for decades.
Established academic medical centers have pain medicine training programs within numerous
medical specialties, and these training programs are recognized for eligibility for board
certification and are recognized by the American Medical Association.
Chronic interventional pain medicine training involves intensive medical training and education
in academic and other medical centers by physicians who are themselves certified as physician
pain medicine specialists.6 The duration of pain management training exceeds by at least one
year the intensive medical residency period, adding one to two years to the duration of
supervised medical interventions and treatments involving full-time patient care and
responsibility as well as participation in research.
Upon completion of a pain management residency, pain physicians are certified by the American
Board of Interventional Pain Physicians (ABIPP). This board is recognized by the American
Board of Medical Specialties (ABMS). The ABIPP certification exam exclusively tests the
physician’s knowledge regarding pain assessment (5%), diagnostic testing (5%), pain syndromes
2
Spine Diagnostics Center of baton Rouge, Inc. v. Louisiana State Board of Nursing, 2008 WL 5351729, p. 14
(La.App. 1 Cir.)
3 Timothy Wayne McDuell v. Health Care Indemnity, Inc., 2001-0057, Medical Review Panel Proceeding, State of
Louisiana.
4
Id.
5
Id.
6
ACGME Program Requirements for Fellowship Education in Pain Medicine. July 1, 2007.
(15%), interventional techniques (15%), and other issues related to the practice of pain
management.7
CRNAs do not possess the requisite education or training to practice medicine and,
particularly, to perform chronic interventional pain management.
Lack of training. Nurse anesthetists are required to have a bachelor’s degree which earns them
an RN designation. They then undergo CRNA training which consists of 18-24 months of
didactic and clinical training in administration of anesthetics. By way of example, CRNAs only
receive a total of six to seven years of total education compared to a physician practicing chronic
interventional pain management who is required to have a minimum education of twelve years,
and several have up to sixteen years of documented education. CRNAs cannot document any
formal education in performing chronic interventional pain management.8 In fact, the College of
Accreditation’s (COA) current standards, last revised in January 2006, do not require nurse
anesthetist programs to provide any clinical case experience in pain management (acute or
chronic).9 Additionally, the COA does not list pain management in the description of “full scope
of practice” for a CRNA.10 This acknowledgment by the national accreditation body that the
medical specialty of chronic interventional pain management is beyond the skills of a CRNA
further supports the separation between nursing and medicine.
Since CRNAs cannot show any formal didactic or clinical training, many justify their
competency to practice medicine by attending a weekend seminar. In a 2008 American Academy
of Pain Management newsletter, it was reported that the American Association of Nurse
Anesthetists was pursuing continuing education shortcuts to expertise in interventional painmanagement techniques.
Through the Institute for Post Graduate Education, AANA is offering a 3-day
Interventional Pain Management Cadaver Model Lab course for CRNAs. The
course’s learning objectives include epidural steroid injections, discography, facet
injections, coding, and cervical, thoracic, and lumbar radiofrequency lesioning.
Although a 3-day comprehensive course in interventional pain management may
not seem adequate for providing comprehensive knowledge in the discipline, it is
the amount of training that most CRNAs receive in the practice of pain
management. The prevailing argument is that doing epidural and selective nerve
blocks for acute pain in the operation room will naturally extend to performing
interventional procedures for chronic pain.11
7
Web. ABIPP Information Bulletin for Certification as Fellow for Interventional Pain Practice.
http://www.abipp.org/forms/diplomate/default.aspx. Retrieved December 3, 2008.
8
Web. University of Iowa College of Nursing Anesthesia Nursing Course Sequence, (www.uiowa.edu). Retrieved
November 24, 2008.
9
COA, Standards for Accreditation of Nurse Anesthesia Education Programs, 2004 edition, revised January 2006.
p. 6-7.
10
Id. Glossary, p. 25. Note that this definition is attributed to “Scope and practice for nurse anesthesia practice,”
available from the AANA.
11
Web. Francis, Michael. LSBN to Allow CRNAs to Practice Pain Management Procedures. Pain Medicine
Network. Winter, 2008. 4. www.painmed.org/pdf/2008winter_newsletter.pdf.
Lack of certification. Unlike physicians, the only certification a CRNA can receive in this area
is from the American Academy of Pain Management (AAPM). In order to sit for the 100
question AAPM certification exam, one must only possess a bachelor’s degree in a health care
related field.12 In addition, the exam rarely contains a single question regarding interventional
pain management. This certification process may better inform a CRNA regarding patient pain
but obviously is not designed to elevate a CRNA to the position of a physician pain specialist.
Rural Access
The Board reviewed state maps demonstrating the location and availability of pain management
specialists throughout Iowa and along its bordering states. The maps show that at any given
location within Iowa a patient’s access to chronic interventional pain management treatment is
never more than 120 miles away. Chronic pain by its own terms (nature) does not require
emergency treatment; rather, it has time to be treated. The availability of such treatment at the
hands of trained specialists is more than sufficient to meet our rural citizen’s needs, while at the
same time removes the risk of patients receiving such treatment form unqualified practitioners.
Conclusion
The Board concludes that the practice of chronic interventional pain management, including the
use of fluoroscopy, is the practice of medicine and is not within the scope of practice of other
health care professionals, including CRNAs. Physicians and osteopathic physicians are trained
to diagnose and treat pain using a myriad of diagnostic techniques and a wide variety of
treatment modalities. Advanced specialty training in chronic interventional pain management
allows for sufficient education in pain, pain management and related areas, e.g., radiology, that
supports the proper performance of chronic interventional pain management. Other health care
professions, including CRNAs, lack the breadth or depth of education and expertise that
physicians and osteopathic physicians possess in chronic interventional pain management. For
this reason the Board finds that specialty trained physicians and osteopathic physicians
credentialed, and actively engaged in, chronic interventional pain management are the most
prepared to offer safe chronic interventional pain management.
The Board recognizes that other health care professionals, including CRNAs, have a great deal to
offer in the treatment of pain and the Board encourages physicians to work cooperatively with
these other health care professionals. However, due to the inherent risks involved in chronic
interventional pain management and the limited education and training possessed by other health
professionals, including CRNAs, the Board finds that other professionals performing chronic
interventional pain management procedures should do so only under the supervision of a
physician or osteopathic physician who is actively engaged in the practice. Physicians and
osteopathic physicians considering such supervision should have an appropriate understanding of
the other health care professional’s training and experience in the proposed procedures.
12
Web. American Academy of Pain Management Credentialing Brochure, revised 01/31/08. www.aapm.com.
Retrieved July, 2008.
Minutes of the Iowa Society of Anesthesiologists: Annual Meeting
Des Moines, IA
04/04/2009
Dr. Allaire convened the meeting at 2:45PM following the Annual Educational meeting.
Minutes were approved from the 2008 meeting, moved by Drs. John Dooley and Steve Stefani.
PRESIDENT’S REPORT
Dr. Allaire discussed the state of the Society’s progress over the past two years in increasing
advocacy and attention from legislators and government officials. The advocacy was born of
direct challenges to anesthesiologists’ reimbursement.
He reviewed the activities of the ISA PAC (see attached) and re-emphasized the need for support
of the PAC.
Dr. Allaire reviewed the concerns regarding patient safety that have been engendered by the
attempt of non-physician practitioners to practice pain medicine. Through active work by Dr.
Rosenquist at the University of Iowa and the officers of the ISA at the Iowa Board of Medicine,
that Board has created a statement supporting the practice of pain medicine as solely the purview
of physicians. Should that statement be finally approved, it will be of help in any further attempts
of other practitioners to obtain ability to practice pain management via legislative or judicial
means. However, it is possible that this may go forward to a legal challenge, with potential
financial impact on the Society.
Dr. Allaire alluded to the improved professional management of the Society with additional
services including an invigorated web presence.
He discussed the decision to retain a new lobbying firm, Policy Works, which the leadership
anticipates will be of value in the Society’s advocacy in the wake of changes in legislative
leadership.
Dr. Allaire asked all to consider the cost of this advocacy and the possible need for dues
increase.
ELECTIONS
Dr. Moyer nominated Dr. Tewfik for Secretary-Treasurer and Dr. Merrill seconded
nomination. Dr. Tewfik was elected by acclaim.
Dr. Cassady will be moving on to President as the inherent termination of his President-elect.
Nominations for President Elect:
Dr. Becker nominated and Dr. Cassady seconded the nomination of Dr. Merrill. No other
nominations were made and Dr. Merrill was elected by acclaim.
Iowa Medical Society Annual Meeting is in two weeks and ISA is eligible for 9 delegates:
members willing to take on that role were Drs. Tewfik, Lederhaus, Merrill and Sundet.
Dr. Douglas Merrill presented the Secretary-Treasurer’s report (attached) and commented on the
increasing deficits, all of which are due to the above-mentioned advocacy. Dr. Merrill mentioned
that the current economic and health-care reform status would likely require further advocacy.
1
ADVOCACY REPORT
Mr. John Cacciatore of Policy Works gave a brief discussion of the legislative landscape in Iowa
and the current state of Medicaid in Iowa. The Federal stimulus package should be of help, as
Iowa Medicaid administrators were suggesting a 4% drop in payments if no stimulus was
forthcoming. Revenues for the State as a whole are expected to be significantly lower than
previous years; so that the stimulus package was appropriated in the Governor’s budget to
maintain Medicaid at ‘status quo’ and that has been re-affirmed as a goal by legislative leaders.
In regard to the general budget, the State departments are seeing budgets cut between 7 and 12%
currently recommended in the Governor’s budget. Other legislative issues were discussed.
BY-LAWS
By-Laws changes – these were approved by acclamation:
1. To allow membership to medical students. This was passed by acclamation.
2. Edits of the By Laws were made to bring them into concordance with actual events regarding
the annual fall meeting.
3. The raise of dues by $100 per member per year.
OLD BUSINESS
A new policy on privacy was requested at the last annual meeting and was prepared (see
attached) and reviewed by the House. It was accepted by acclamation.
NEW BUSINESS
ISA is entitled to appoint a member of the Carrier Advisory Committee; John Dooley
expressed interest and was appointed by the Society president.
Respectfully Submitted,
Dr. Doug Merrill
Secretary-Treasurer
2
Anesthesia Services for Gastrointestinal Endoscopic Procedures
4/24/09 9:25 AM
Anesthesia Services for Gastrointestinal Endoscopic Procedures
Medical Policy: 07.01.45
Original Effective Date: July 2009
Reviewed:
Revised:
This policy applies to all products unless specific contract limitations, exclusions or exceptions apply.
Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to
referral authorization, and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
This policy is effective July, 2009
This medical policy addresses anesthesia services during gastrointestinal endoscopic procedures.
Anesthesia services include all services associated with the administration and monitoring of
analgesia/anesthesia to a patient in order to produce partial or complete loss of sensation. Examples of
various methods of anesthesia include moderate sedation, monitored anesthesia care, regional anesthesia
and general anesthesia.
Policy:
Moderate sedation may be considered medically necessary when administered to average-risk adult
patients undergoing general, diagnostic, uncomplicated, therapeutic endoscopy and colonoscopy.
Other types of anesthesia services including monitored anesthesia care and general anesthesia may be
considered medically necessary during gastrointestinal endoscopic procedures when there is
documentation by the operating physician and the anesthesiologist of any of the following circumstances:
A history of or anticipated intolerance to standard sedatives (i.e., patient is on chronic narcotic or
benzodiazepine therapy, or has a neuropsychiatric disorder)
Increased risk of complications due to a severe co morbidity (American Society of
Anesthesiologists [ASA] class III physical status or greater). See additional information below.
Prolonged or therapeutic endoscopic procedure requiring deep sedation
Pediatric age group (younger than 18 years)
Pregnancy
History of drug or alcohol abuse
Uncooperative or acutely agitated patient (i.e., delirium, organic brain disease, senile dementia)
Increased risk for airway obstruction due to anatomic variant including any of the following:
History of previous problems with anesthesia or sedation
History of stridor or sleep apnea
Dysmorphic facial features
Presence of oral abnormalities including but not limited to small oral opening (less than 3 cm
in an adult), high arched palate, macroglossia, tonsillar hypertrophy, or non-visible uvula
http://www.wellmark.com/e%5Fbusiness/provider/medical%5Fpolicies/policies/_Anesthesia_Services.htm
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Anesthesia Services for Gastrointestinal Endoscopic Procedures
4/24/09 9:25 AM
Neck abnormalities including but not limited to short neck, obesity involving the neck and
facial structures, limited neck extension, decreased hyoid-mental distance (less than 3 cm in
an adult), neck mass, cervical spine disease or trauma, tracheal deviation, or advanced
rheumatoid arthritis
Jaw abnormalities including but not limited to micrognathia, retrognathia, trismus, or
significant malocclusion.
The routine assistance of an anesthesiologist or a certified registered nurse anesthetist (CRNA) for
average-risk adult patients undergoing standard upper and/or lower gastrointestinal endoscopic procedures
is considered not medically necessary.
Additional Information:
American Society of Anesthesiology Physical Status Classification:
Class I: Patient has no organic, physiologic, biochemical, or psychiatric disturbances. The pathologic
process for which operation is to be performed is localized and does not entail systemic disturbance.
Class II: Mild or moderate systemic disturbance caused either by the condition to be treated surgically or
by other pathophysiologic processes
Class III: Severe, systemic disturbance or disease from whatever cause, even though it may not be
possible to define the degree of disability with finality.
Class IV: Severe systemic disorders that are already life threatening, not always correctable by operation.
Class V: The moribund patient who has little chance of survival but is submitted to operation in
desperation.
Top
Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level
2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal
to duodenum
00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to
duodenum
Top
Selected References:
Standards of Practice Committee, Lichtenstein DR, Jagganath S, Baron TH et al. Sedation and
anesthesia in GI endoscopy. Gastrointest Endosc. 2008 August;68(2):205-16.
Cohen LB, Delegge MH, Aisenberg J et al. AGA Institute Review of Endoscopic Sedation.
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Anesthesia Services for Gastrointestinal Endoscopic Procedures
4/24/09 9:25 AM
Gastroenterology2007 August;133(2):675-701.
American Society of Anesthesiologists Task Force on Sedation and Analgesia by NonAnesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists.
Anesthesiology. 2002; 96(4):1004-1017.
Top
New information or technology that would be relevant for Wellmark to consider when this policy is next
reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2009 American Medical Association. All Rights Reserved.
Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc. They are developed to assist in
administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan
or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely
responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.
http://www.wellmark.com/e%5Fbusiness/provider/medical%5Fpolicies/policies/_Anesthesia_Services.htm
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ISA PAC 2009 Contributors
Thanks for your contribution. Remember that you can
make ISA PAC contributions online at the ISA website –
www.iasocanes.org.
Janet Acarregui MD
Richard Aerts MD
Patrick Allaire MD
Michael Almasi DO
Jeffrey Anderson MD
James Becker MD
Robert Beckman MD
Christine Botkin MD
Brian Bowshier M.D.
Johnny Brian Jr. MD
Jeffrey Buffo MD
David Burkamper MD
Christine Carstensen MD
Joseph Cassady Jr. MD
Meredith Crenshaw MD
Kent Croskey DO
David Crumley MD
Louis DeWild MD
Judith Dillman MD
John Dooley MD
Carrie Dykstra MD
Robert Fears MD
Ivan Fomitchev MD
Courtney Hancock MD
Tork Harman MD
Maurice Hart MD
David Haupt MD
John Herring MD
Bradley Hindman MD
John Jabour MD
Jamie Johnson MD
Susan Karr-Peterson DO
Robert Kitterman III MD
Mark Kline MD
George Lederhaas MD
Jessica Leinen MD
David Lind MD
Nancy Lorenzini MD
Stephen Maze MD
Paula McFadden MD
Douglas Merrill MD
John Moyers MD
Scott Murtha MD
Trevor Ponte DO
Robert Rossi, MD
Julie Saddler MD
Douglas Sedlacek MD
Gary Shanks MD
John Skoumal MD
David Stein MD
Hans Steine MD
Lois Stoltze MD
Christopher Teggatz MD
Sherif Tewfik MD
Gail Vandewalker MD
Jason Walker MD
Christopher Walsh MD
Timothy Walsh MD