After Blue Cross Blue Shield of North Carolina released revised guidelines on coverage for spinal fusions in Sept. 2010, leaders of orthopedic and spine societies from around the country collaborated on a formal response. In a letter, written largely by members of the American Association of Neurological Surgeons and signed by nine different organizations including the North American Spine Society, Spine Arthroplasty Society and American Academy of Orthopaedic Surgeons, spine surgeons made recommendations to the NCBCBS for changes to the coverage policy. Charles L. Branch, Jr., MD, chair of neurology at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., was instrumental in representing neurosurgeons in these efforts.
"There are several good, well meaning people arguing from both sides of the aisle about the efficacy of lumbar fusion for people who have pure, actual back pain with a degenerative spine," says Thomas Errico, MD, president of the Spine Arthroplasty Society--International Society for the Advancement of Spine Surgery. For him, there is sufficient evidence within the literature to support performing spinal fusions on appropriately indicated patients.
The decision for NCBCBS to eliminate coverage for spinal fusions was made as a result of the insurer seeking to decrease expenditures for degenerative disc disorder (DDD). "They were looking to diminish the volume of procedures they would cover and the most frequent cases they saw for spinal fusions were lumbar DDD," says Dr. Errico. "They noticed they had a large increase in costs for lumbar fusions and thought it warranted being tighter on what they would cover."
Discussion with NCBCBS
Several of the organization leaders, including Dr. Errico, spoke with NCBCBS and learned the payor had made some of the recommended changes. These recommendations were made after reviewing studies on spinal fusions showing good patient outcomes. "It takes a lot of work to draft guideline recommendations and put evidence together," says Dr. Errico. "When we spoke with NCBCBS, we were pleasantly surprised to see they had revised the policy and incorporated most of the changes we had suggested to them."
The revised policy includes adding coverage on Flatback osteotomy fusions and the separation of pediatric surgeries from these guidelines. The NCBCBS still will not coverage pure spinal fusions for DDD, though the insurer has not yet closed the door on approvals for that on appeal, according to an ISASS news release.
One of the major focuses of the recommendations was looking for coverage on decisions for cases where there isn't a classic indication for spinal fusion. For example, if the surgeon begins performing a spinal decompression and the decompression is too wide, the patient might need a fusion to stabilize the spine. This happens on a rare occasion, says Dr. Errico, but the group of surgeons advocated for coverage in these types of instances. NCBCBS responded that when these types of cases occur, their representatives could most likely work with the surgeon to insure coverage.
Using Milliman Care Guidelines for coverage
While the leaders of these societies have won a small battle in North Carolina, the war continues on a national level because several insurers continue to have very restrictive policies on spinal fusions, says Dr. Errico. Some of these insurance companies are basing coverage decisions on the Milliman Care Guidelines, which are industry-generated guidelines for performing surgeries. The guidelines aren't coming out of an academic center or specialty society.
"The guidelines are geared toward the insurance companies and insurance companies are using them to define coverage," says Dr. Errico. "I think these guidelines need to be seriously looked at by the physician specialty societies to see if we agree with them."
The Milliman Care Guidelines consider lumbar fusion medically necessary in a few instances, including when the patient has a spinal fracture and spinal instability or neural compression; spinal repair in operations for dislocation, abscess or tumors; and spinal tuberculosis.
For degenerative scoliosis, the guidelines indicate the patient must have a deformity of greater than 50 degrees with loss of function, persistent significant radicular pain or weakness or persistent neurogenic claudication unresponsive to conservative care. Further recommendations for spinal fusions to treat stenosis and spondylolysis have specific requirements patients must achieve before surgery is recommended, including failure of at least three months of conservative care.
New technology in spine surgery
As new technology and procedures come out, insurance companies will decide whether to cover the procedures based on whether the increased cost justifies the benefits for the patient. "People come to the take with different biases," says Dr. Errico. "Some people are skeptical of change and others embrace new technologies. I am someone who is skeptical of new technology, but I do believe new technology will bail us out of our situation in some respect."
New innovations in the future will find cost-effective ways to produce good outcomes for patients. Now, surgeons and innovators need to look at the old technologies and ask whether we really need to pay for it, or if there are better ways to produce the technology.
Learn more about ISASS.
Read more about spinal fusions:
- Spinal Fusions Face an Uncertain Future
- The ISASS Defends Spinal Fusions
- Report Investigates Spinal Fusions Performed By Twin Cities Spine Surgeons
"There are several good, well meaning people arguing from both sides of the aisle about the efficacy of lumbar fusion for people who have pure, actual back pain with a degenerative spine," says Thomas Errico, MD, president of the Spine Arthroplasty Society--International Society for the Advancement of Spine Surgery. For him, there is sufficient evidence within the literature to support performing spinal fusions on appropriately indicated patients.
The decision for NCBCBS to eliminate coverage for spinal fusions was made as a result of the insurer seeking to decrease expenditures for degenerative disc disorder (DDD). "They were looking to diminish the volume of procedures they would cover and the most frequent cases they saw for spinal fusions were lumbar DDD," says Dr. Errico. "They noticed they had a large increase in costs for lumbar fusions and thought it warranted being tighter on what they would cover."
Discussion with NCBCBS
Several of the organization leaders, including Dr. Errico, spoke with NCBCBS and learned the payor had made some of the recommended changes. These recommendations were made after reviewing studies on spinal fusions showing good patient outcomes. "It takes a lot of work to draft guideline recommendations and put evidence together," says Dr. Errico. "When we spoke with NCBCBS, we were pleasantly surprised to see they had revised the policy and incorporated most of the changes we had suggested to them."
The revised policy includes adding coverage on Flatback osteotomy fusions and the separation of pediatric surgeries from these guidelines. The NCBCBS still will not coverage pure spinal fusions for DDD, though the insurer has not yet closed the door on approvals for that on appeal, according to an ISASS news release.
One of the major focuses of the recommendations was looking for coverage on decisions for cases where there isn't a classic indication for spinal fusion. For example, if the surgeon begins performing a spinal decompression and the decompression is too wide, the patient might need a fusion to stabilize the spine. This happens on a rare occasion, says Dr. Errico, but the group of surgeons advocated for coverage in these types of instances. NCBCBS responded that when these types of cases occur, their representatives could most likely work with the surgeon to insure coverage.
Using Milliman Care Guidelines for coverage
While the leaders of these societies have won a small battle in North Carolina, the war continues on a national level because several insurers continue to have very restrictive policies on spinal fusions, says Dr. Errico. Some of these insurance companies are basing coverage decisions on the Milliman Care Guidelines, which are industry-generated guidelines for performing surgeries. The guidelines aren't coming out of an academic center or specialty society.
"The guidelines are geared toward the insurance companies and insurance companies are using them to define coverage," says Dr. Errico. "I think these guidelines need to be seriously looked at by the physician specialty societies to see if we agree with them."
The Milliman Care Guidelines consider lumbar fusion medically necessary in a few instances, including when the patient has a spinal fracture and spinal instability or neural compression; spinal repair in operations for dislocation, abscess or tumors; and spinal tuberculosis.
For degenerative scoliosis, the guidelines indicate the patient must have a deformity of greater than 50 degrees with loss of function, persistent significant radicular pain or weakness or persistent neurogenic claudication unresponsive to conservative care. Further recommendations for spinal fusions to treat stenosis and spondylolysis have specific requirements patients must achieve before surgery is recommended, including failure of at least three months of conservative care.
New technology in spine surgery
As new technology and procedures come out, insurance companies will decide whether to cover the procedures based on whether the increased cost justifies the benefits for the patient. "People come to the take with different biases," says Dr. Errico. "Some people are skeptical of change and others embrace new technologies. I am someone who is skeptical of new technology, but I do believe new technology will bail us out of our situation in some respect."
New innovations in the future will find cost-effective ways to produce good outcomes for patients. Now, surgeons and innovators need to look at the old technologies and ask whether we really need to pay for it, or if there are better ways to produce the technology.
Learn more about ISASS.
Read more about spinal fusions:
- Spinal Fusions Face an Uncertain Future
- The ISASS Defends Spinal Fusions
- Report Investigates Spinal Fusions Performed By Twin Cities Spine Surgeons