A spine surgeon can decide a fusion, disc replacement or decompression is the right operation. That does not always mean the case will move forward as planned.
Across recent Becker’s reporting, spine surgeons have described payer rules reaching deeper into the treatment pathway: requiring more granular justification for fusion, limiting some motion-preserving approaches, adding steps before surgery, influencing site of care and changing the economics of which procedures remain sustainable.
The common thread is not that insurers make the clinical decision. It is that coverage and payment policies can shape which options are practically available after that decision is made.
Here are seven places where that pressure is showing up.
1. Fusion approval is becoming more granular: Getting a spinal fusion approved can require far more than establishing that surgery is medically necessary.
Spine surgeons recently told Becker’s that some insurers are asking for the exact graft and implant names planned for surgery, level-by-level CPT coding, imaging and detailed documentation of failed conservative treatment. CMS has also brought traditional Medicare further into the equation in six states through its WISeR model, which includes cervical fusion among the services subject to prior authorization or prepayment medical review.
Bryce Basques, MD, director of minimally invasive and endoscopic spine surgery at Brown University in Providence, R.I., said insurer algorithms can also make the terminology in the medical record part of the approval process.
“Writing notes no longer means documenting medical decision-making,” Dr. Basques told Becker’s. The result is a second layer of work after the surgeon decides fusion is appropriate: building a record that satisfies the payer’s specific criteria.
2. Motion preservation can hit a coverage ceiling: Spine surgeons have more alternatives to fusion than they did a decade ago. Cervical disc replacement has matured, while decompression, endoscopy and laminoplasty can preserve motion in appropriately selected patients.
But the evidence and the coverage policies do not always move together.
Wilson Ray, MD, chief of spine surgery and vice chair of neurosurgery at Washington University School of Medicine in St. Louis, recently pointed to hybrid cervical procedures as one example. One spinal level may be best suited to disc replacement while an adjacent level requires fusion, but insurers can categorize the combined approach as experimental.
“That has continued to be a point of frustration,” Dr. Ray told Becker’s. Lumbar disc arthroplasty can create similar coverage challenges. That means a surgeon may identify a motion-preserving option as clinically appropriate and still face a separate question over whether the insurer recognizes that treatment strategy.
3. Prior authorization can change the treatment sequence: Payer requirements can affect more than whether surgery happens. They can determine what a patient must complete, and sometimes repeat, before reaching the operating room.
Kasra Ahmadinia, MD, of Tulsa-based Advanced Orthopedics of Oklahoma, described a patient whose authorization process stretched nearly six months as the insurer required physical therapy, injections and waiting periods. By the time those requirements were completed, he said, the earlier physical therapy was considered outdated and had to be repeated.
“The goalposts are moved all the time,” Dr. Ahmadinia told Becker’s.
Some insurers are easing requirements in selected areas. UnitedHealthcare will eliminate prior authorization for certain spine surgery CPT codes across Medicaid managed care plans in 16 states and the District of Columbia beginning Oct. 1. The changes include certain vertebral excisions and spinal instrumentation removal procedures, with some laminectomy and intraspinal lesion codes included in most affected markets.
But recent surgeon responses suggest the larger issue is increasingly which procedures remain subject to review. Justin Iorio, MD, an orthopedic spine surgeon at St. Joseph’s Physicians Orthopedics in Fayetteville, N.Y., told Becker’s that high-cost lumbar and cervical fusions remain among the procedures attracting the greatest scrutiny.
Surgeons raised similar concerns after UnitedHealthcare announced reductions in prior authorization requirements. In reactions gathered by Becker’s, physicians said eliminating authorization for selected services does not necessarily address the procedures generating the greatest administrative burden.
4. Payment can favor the bigger operation: Prior authorization affects whether an operation gets approved. Reimbursement can create another pressure: whether a practice can sustainably provide it.
Peter Derman, MD, an endoscopic and minimally invasive spine surgeon in Dallas, has pointed to a mismatch between the economics of less invasive procedures and larger operations. “The U.S. healthcare system financially incentivizes big fusion surgeries over outpatient, ultra-minimally invasive decompressions,” Dr. Derman told Becker’s.
As practice costs increased and payments for smaller procedures declined, Dr. Derman said maintaining a focus on endoscopic techniques became unsustainable within the traditional insurance model. He ultimately moved to direct pay. That creates an uncomfortable dynamic as spine surgery simultaneously moves toward smaller operations for some patients: The less invasive procedure can be clinically attractive while becoming more difficult to support financially.
5. Payer policy can influence where surgery happens: The same tension extends to site of care. Advances in minimally invasive surgery, anesthesia, recovery protocols and patient selection have expanded the range of spine procedures that can be performed in ASCs. But payer policies can still rely on older assumptions about which cases belong in hospitals.
Sean Gipson, CEO and ASC division president of Remedy Surgery Center in Houston, described the disconnect succinctly: “Complexity is evolving faster than policy.”
He pointed to one- to three-level anterior cervical discectomy and fusions, lumbar decompressions and select minimally invasive fusions as procedures increasingly performed in outpatient settings at mature spine programs, while some payer policies continue to default to hospital-based care. The issue is not simply whether a procedure can technically move outpatient. Coverage, implant reimbursement and site-of-service rules can determine whether doing so is financially viable.
6. Reimbursement can reach the hardest cases: The impact becomes particularly consequential in complex spine surgery, where long operating times, instrumentation, biologics and extensive perioperative care already make cases expensive.
Richard Menger, MD, chief of complex spine surgery and vice chair of neurosurgery at USA Health in Mobile, Ala., recently told Becker’s that reimbursement structures do not always capture the difference between a relatively straightforward operation and technically demanding deformity or revision surgery. The incentive structure matters, he said.
“If you’re going to take away incentives to do certain surgeries, you’re going to have fewer of those surgeries,” Dr. Menger said.
CMS is making some changes. Three new Medicare severity diagnosis-related groups for extensive or complex spinal fusion procedures take effect Oct. 1. But Dr. Menger said the change primarily helps recognize complexity on the hospital side and does not necessarily account for the additional surgeon work involved in difficult cases.
That raises a broader access question: If the most difficult operations require substantially more resources without corresponding payment, who will continue taking them on?
7. Even prior authorization may not guarantee payment: Approval does not necessarily end the payer decision. The American Association of Orthopaedic Surgeons is backing federal legislation that would restrict Medicare Advantage insurers from reversing coverage decisions after care has already been provided. AAOS said plans can retroactively deny coverage, reduce payment or seek repayment after procedures that received prior authorization or did not require it.
Dr. Iorio raised the same concern when discussing UnitedHealthcare’s prior authorization changes. “Obtaining prior authorization, or not needing it, does not mean payment will be rendered; it can still be denied retroactively,” he told Becker’s.
For practices, that means payer influence can extend from authorization through payment. Taken together, these pressure points show how coverage and reimbursement rules can shape not only whether spine surgery moves forward, but which options are realistically available to surgeons and patients.
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.
