Reimbursement pressure in spine is not affecting every procedure in the same way.
Some surgeons say newer, less invasive approaches are difficult to sustain under existing payment structures, while others argue the most complex operations are being squeezed as implant, staffing and hospital costs rise faster than reimbursement.
Here are five areas spine surgeons have identified as particularly strained:
1. Endoscopic and minimally invasive decompressions: For Peter Derman, MD, an endoscopic and minimally invasive spine surgeon in Dallas, the reimbursement problem is particularly pronounced for outpatient, ultraminimally invasive decompressions.
Dr. Derman said the current system can financially favor larger fusion procedures over less invasive approaches, even when he believes the smaller procedure is more appropriate for the patient. As practice costs increased and payments for smaller procedures declined, he ultimately moved to a direct-pay model.
The issue extends beyond individual payer contracts. Brandon Hirsch, MD, an orthopedic spine surgeon at DISC Sports and Spine Center in Newport Beach, Calif., has argued that endoscopic spine procedures need reimbursement that accounts for the equipment and resources required by newer techniques.
CMS has taken some steps to address coding issues around endoscopic care. For 2026, the agency increased the medically unlikely edit for CPT 64772 from two units to six, a change affecting endoscopic medial branch transection. But surgeons have continued to raise broader concerns about whether reimbursement has kept pace with newer minimally invasive approaches.
2. Cervical disc replacement: Cervical disc arthroplasty has surfaced repeatedly in surgeon concerns about reimbursement. Dr. Derman called cervical and lumbar disc replacement “similarly undervalued” alongside minimally invasive decompression procedures when discussing why he ultimately left traditional insurance reimbursement behind.
Ernest Braxton, MD, a partner at Vail (Colo.) Summit Orthopaedics and Neurosurgery, also identified cervical disc arthroplasty in the Medicare Advantage population as one of the procedures facing the greatest reimbursement pressure. Dr. Braxton said the squeeze is not driven by a single rate cut. Flat commercial rates, rising implant costs, prior authorization and post-payment denials can combine to weaken the economics of the procedure.
3. Multilevel lumbar fusion: Multilevel lumbar fusion is another procedure spine leaders say is becoming harder to make financially sustainable. Dr. Braxton pointed specifically to multilevel lumbar fusions in Medicare Advantage as among the procedures being squeezed hardest.
James Rizkalla, MD, clinical assistant professor of orthopedic surgery and medical director for orthopedic research at Texas A&M School of Medicine and Baylor University Medical Center in Dallas, similarly identified multilevel fusion as a high-cost procedure for which reimbursement is failing to keep pace with implant costs, operating room time and hospital resources.
That pressure comes as spine surgeons face broader Medicare headwinds. Under CMS’ proposed 2027 Physician Fee Schedule, orthopedic surgery payments are estimated to decline 7% from proposed relative value unit and coding changes, while neurosurgery is estimated to decline 2%. Those estimates are national averages and separate from the proposed conversion-factor reductions. Several common spine pain procedures would also see lower ASC facility payments under the proposal.
4. Revision spine surgery: Revision surgery presents a different reimbursement problem: The case may demand significantly more time and resources without a proportional increase in payment. Dr. Rizkalla included revision spine surgery among the procedures under the greatest financial pressure, pointing to the combination of implant expense, operative time and hospital resources.
The concern fits into a broader criticism of how complex spine surgery is valued. Michael Gross, MD, orthopedic director of Union Middlesex Orthopedics in Woodbridge, N.J., has argued that Medicare’s payment structure does not adequately account for case complexity.
Under the current structure, he noted, the same procedure code can apply to a relatively healthy patient and a patient with significant comorbidities, despite differences in technical difficulty, operative time, complication risk and postoperative management. That can leave surgeons taking on the most difficult patients without corresponding reimbursement for the added work and risk.
5. Adult spinal deformity surgery: Complex deformity procedures are among the spine surgeries where reimbursement has struggled to keep pace with rising implant costs, operating room time and hospital resource use, according to Dr. Rizkalla,
The challenge is compounded by how Medicare accounts for the complexity of these cases. A 2026 study of 314 adult spinal deformity patients found significant variation within Medicare’s spinal deformity-specific DRGs in patient frailty, surgical invasiveness, postoperative ICU and hospital stays, complications and reimbursement. Researchers concluded the existing DRGs were not reliable gauges of patient and surgical complexity or reimbursement costs.
Other spine surgeons have raised similar concerns about the sustainability of complex deformity care. Brian McHugh, MD, of McHugh Neurosurgery in West Islip, N.Y., said high-acuity cases such as deformity corrections require significant time, resources and experienced teams, and become harder for specialized independent practices to sustain when reimbursement does not reflect that complexity.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
