Nearly a year after the Blue Cross and Blue Shield of Kansas made coverage changes to their spinal fusion policy, the local news source KAKE.com reports patients are having a harder time accessing spine surgery.
The article follows a patient who has been denied spinal fusion twice by BCBS of Kansas, her insurer. Here are five things to know about the coverage changes:
1. The policy change went into effect in July 2013, requiring more non-surgical care and documentation before the insurer will cover lumbar spinal fusions. Manager of Corporate Communications for Blue Cross Blue Shield of Kansas Mary Beth Chambers said the policy change was made after reviewing a new body of research done in the past 10 years on the effectiveness of spinal fusion. The North American Spine Society released Coverage Policy Recommendations for Lumbar Spinal Fusion earlier this year, designed to help surgeons, providers, patients and payers make decisions about surgical intervention.
Many surgeons are reporting similar issues with coverage denials for spinal fusion, and GlobalData cut their predictions for annual growth in the spinal fusion market in half due to reimbursement issues where "payers require extensive documentation to validate the medical necessity of the procedure, including well-documented attempts at conservative care and radiographic imaging to record the source of pain."
2. The new policy requires patients to first try all other non-surgical options over a period of time and show documentation. The documentation must include diagnostic scans with evidence of a condition, physical therapy attempts, prescription-strength anti-inflammatory and continued functional impairment and pain after treatment, according to the report.
Despite the difficulty achieving coverage, many analysts still predict around 5 percent annual growth in spinal fusions over the next five to eight years due to the increased aging population and refined surgical technique. A Global Analyst and Market Forecasts report notes that the United States market is one of the biggest for spinal fusions in the world "as a result of the clinical success among appropriately-indicated patients."
3. For BCBS of Kansas members, the patient's documentation now goes through a lengthy review process, beginning with a precertified nurse. The documentation is also reviewed by an independent spine surgeon, according to the report.
4. If the patient's surgery is not deemed medically necessary by the initial review, the case can be appealed. At that time, there is a peer-to-peer review with an "expert." The "expert" is often out-of-state, notes the report, "because of a lack of local available experts." The expert will speak with the patient's spine surgeon about the case. If this expert also denies coverage, the patient can appeal to other external experts through the Kansas Insurance Department.
5. The patient profiled within the report said she and others felt they had the necessary documentation and went through the appeals process, but are still unable to obtain coverage for spinal fusion. Three different BCBS of Kansas in-network surgeons told the patient she needs surgery. The International Society for the Advancement of Spine Surgery launched the International Advocates for Spine Patients group to connect and help patients who are denied surgery their surgeon deemed medically necessary.
A ReportsnReports analysis estimate places the spinal fusion market at $6.9 billion by 2020, noting there are now some motion-sparing techniques gaining steam. Millennium Research Group places the global spinal non-fusion market at $1.6 billion in 2022, nearly tripling in size.
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