The draft policy would disqualify some patients with chronic low back pain who don't respond to the appropriate non-operative care from receiving coverage for spinal fusions. "Given that all patients are different, sweeping policy statements will exclude properly selected patients from receiving appropriate clinical care," Dr. Garfin wrote in the letter.
The specific concerns outlined in the letter include:
• The exclusion of the potential role of lumbar fusion when treating lumbar instability apart from an accompanying fracture, in addition to other areas the policy fails to address.
• Spondylolisthesis without slippage is not included as a covered indication.
• Lumbar fusion for patients with just degenerative disc disease is ruled out by the policy.
• The policy does not address fusion for patients with degenerative spondylolisthesis with or without neurologic compromise.
In his letter, Dr. Garfin mentions that other carriers and agencies have instituted criteria for the appropriate use of lumbar fusion for patients with DDD, including those who have debilitating pain despite a minimum of six moths of nonsurgical therapy, including psychosocial assessment and treatment; focal disease ad evidence of DDD on an MRI or concordant pain on provocative discography.
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ISASS: 4 Concerns With BCBS of Illinois Lumbar Fusion Draft Policy FeaturedWritten by Laura Miller | June 07, 2012
President of the International Society for the Advancement of Spine Surgery Steven Garfin, MD, discussed four areas of concern over the BCBS of Illinois draft policy on lumbar spinal fusions in a letter to the Medical Director of Medical Policy and Adjustment for the Blue Cross Blue Shield of Illinois Will Harms, MD.
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