Blue Cross of Philadelphia has issued a policy update that requires a physiatrist to attest that a patient failed conservative treatment prior to lumbar spinal fusions.
The IBC Policy 11.14.27d-Spinal Fusion states: "Lumbar spinal fusion is considered medically necessary and, therefore covered when any of the following criteria are met; and a physiatrist consultation has been completed to confirm the failures of nonsurgical options"
The International Society for the Advancement of Spine Surgery sent a letter to the Independence Blue Cross Medical Policy Team on Aug. 25 questioning the policy. In the letter, ISASS questions the level of evidence supporting the consultation with a physiatrist to document that the patient has exhausted all nonoperative options prior to surgery and noted that spine surgeons should make the decision about whether surgery is necessary.
The letter also cited Goodman et al, which found that mandatory prior authorization physiatrist screening for elective lumbar fusions in the non-Medicare population increased the low back pain episodes by around one year with more pre-surgical care, including spinal injections and inpatient admissions. The letter also noted Phillips et al, a literature review, found that lumbar spinal fusion for chronic lower back pain due to degenerative disc disease is a viable treatment to reduce pain and improve function.
"ISASS remains concerned by this egregious overreach by Blue Cross of Philadelphia and believes that there will [be] deleterious repercussions for spine patients," wrote Frank Phillips, MD, and Morgan Lorio, MD, in the letter. ISASS welcomed the opportunity to speak with the payer and discuss implications of the new policy.
To view the ISASS Policy Statement on Lumbar Spina Fusion, click here.