The surgeon may still make the final decision in the operating room, however, many of the decisions that determine whether a patient ever gets there are happening somewhere else.
Insurers, algorithms, reimbursement formulas, referral pathways and federal payment models are influencing when patients reach surgeons, which treatments they must try first, what documentation counts as proof, which procedures are covered and whether complex care remains financially sustainable.
Becker’s recent reporting shows eight places where spine surgeons say control over the patient pathway is shifting:
1. Prior authorization can determine when, or whether, surgery happens: Kasra Ahmadinia, MD, director of minimally invasive spine surgery at Advanced Orthopedics of Oklahoma in Tulsa, described one patient who waited nearly six months for surgical approval.
The patient completed physical therapy, injections and insurer-mandated waiting periods. By the time approval was sought again, the insurer considered the earlier physical therapy outdated and required another round.
“The goalposts are moved all the time,” Dr. Ahmadinia told Becker’s.
He said some patients eventually abandon surgery altogether after repeatedly confronting new requirements.
2. Algorithms are changing how surgeons document clinical decisions: The issue increasingly goes beyond whether a surgeon believes an operation is medically necessary. Approval can depend on whether the medical record uses the precise terminology an insurer’s system expects.
Bryce Basques, MD, spine surgeon and director of minimally invasive and endoscopic spine surgery at Brown University in Providence, R.I., told Becker’s that algorithmic prior authorization varies by insurer and can turn clinical documentation into an exercise in satisfying automated criteria.
“Writing notes no longer means documenting medical decision-making,” he said.
Other spine surgeons described increasingly granular requirements around conservative care, CPT codes, implants, graft materials and specific wording. A missing element can trigger a denial before a physician reviewer ever sees the case.
3. Payers can dictate what patients must fail before receiving definitive treatment: Prior authorization often requires patients to complete specific courses of physical therapy, medications or injections before surgery is approved, even when surgeons question whether those steps will change the outcome.
A 2026 study from OrthoCarolina Research Institute examined more than 7,000 patients recommended for elective surgery for degenerative spine disease. Insurers initially denied 460 patients, or nearly 7%. In 138 cases, the denial stemmed from insufficient documentation of six weeks of physical therapy.
Among patients who underwent surgery after an initial denial, the average delay was 15.7 days.
“Patients had to live with the pain that restricted their work, family and community activities,” study leader Rob Turk, MD, said. The researchers concluded prior authorization delayed care without reducing costs.
4. Peer-to-peer reviews can pull surgeons away from the patients directly in front of them: Adetokunbo Oyelese, MD, PhD, director of the spinal surgery division and Norman Prince Spine Institute at Brown University Health in Providence, told Becker’s he has stepped out of patient visits, and even scrubbed out of operations, to take insurer peer-to-peer calls.
The irony is difficult to miss: A surgeon leaves one patient to defend a clinical decision already made for another.
Dr. Oyelese does not argue that utilization review has no role. He said inappropriate spine surgery has contributed to payer scrutiny. His concern is when the process becomes more focused on finding documentation deficiencies than assessing the individual patient.
5. Coverage policies can narrow which operation a patient receives: Payer control does not stop at whether surgery is approved. It can extend to the type of operation a surgeon is able to offer.
Thomas McNally, MD, director of spine surgery at Weiss Memorial Hospital in Chicago, told Becker’s that endoscopic spine procedures and newer techniques can remain difficult to secure coverage for despite growing clinical adoption.
When less-invasive treatment is denied, he said, patients can be left to “either accept a more invasive surgery or live with ongoing pain and disability.”
The issue is also showing up at the implant level. Jacky Yeung, MD, a Yale Medicine neurosurgeon in New Haven, Conn., said authorization requests that once centered on whether fusion was necessary increasingly ask for the exact graft material and implant names surgeons intend to use.
6. Surgeons do not always control when the right patient reaches them: Control can be lost before the authorization process even begins.
Khalid Odeh, MD, attending spine surgeon at Corewell Health in Royal Oak, Mich., has described a fragmented referral system in which patients who ultimately need surgery may spend too long in nonsurgical treatment, while patients likely to improve without surgery arrive at surgical clinics too early.
Some spine practices are using structured and AI-supported triage to regain control of that front end. Michael Verdon, MD, a spine surgeon with Dayton (Ohio) Neurologic Associates, said his practice’s algorithmic triage system doubled clinic throughput and increased surgical volume about 10%.
“The patients get early treatment with the right person at the right time,” Dr. Verdon said.
The larger shift is important: Who designs the intake pathway increasingly determines which patients reach the surgeon, and when.
7. Reimbursement is influencing which care remains economically possible: Surgeons can believe a procedure is appropriate and still operate within a system where the economics determine whether an organization can continue offering it.
Brian McHugh, MD, of McHugh Neurosurgery in West Islip, N.Y., told Becker’s that deformity corrections, revision procedures and other high-acuity cases require substantial operating time, infrastructure and experienced teams. As reimbursement fails to keep pace with those costs, sustaining those services becomes increasingly difficult.
Vijay Yanamadala, MD, of Hartford (Conn.) HealthCare, described “difficult tension between what patients need and what’s economically sustainable.”
He also pointed to another misalignment: Time spent counseling a patient against unnecessary surgery and coordinating conservative care often pays substantially less than procedural volume.
8. CMS is moving financial accountability from the institution to the individual surgeon: The next shift may be less visible to patients but consequential for physicians.
CMS’ mandatory Ambulatory Specialty Model begins its first performance year Jan. 1, 2027, for certain specialists treating Medicare patients with low back pain in selected markets. Unlike earlier value-based programs, where hospitals or accountable care organizations largely held the risk, ASM scores individual clinicians.
Participants are evaluated on cost, quality, care improvement activities and interoperability. The model’s risk corridor starts at plus or minus 9% of Medicare Part B payments and eventually reaches 12%. The adjustment is not confined to low back pain claims.
There is also no opt-out for clinicians who meet CMS’ participation criteria.
That does not mean CMS is choosing an operation for the surgeon. It does mean decisions across an episode, referrals, imaging, nonsurgical treatment, surgery and downstream utilization increasingly carry financial consequences attached directly to the physician.
None of these forces eliminates physician judgment. Surgeons still determine whether an operation is clinically appropriate and how it should be performed.
What is changing is how much of the pathway surrounding that decision remains theirs to control. By the time a spine surgeon meets a patient, an insurer may have determined which treatments must come first. An algorithm may determine whether the documentation is sufficient. A referral system may determine how long the patient waited. A coverage policy may narrow the available procedure, and a reimbursement model may determine whether the care can be sustainably delivered at all.
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.
