Although more spine and orthopedic procedures are shifting to outpatient settings, some cases have faced roadblocks with migration.
Spine and orthopedic surgeons discuss the outpatient procedures that they’re struggling with the most from payers.
Note: Responses were lightly edited for clarity.
Question: Which spine or orthopedic procedures are facing the most pushback from payers when transitioning to ASCs? How is your team responding to specific codes or case types that are triggering frequent denials, downcoding or prior authorization hurdles?
Josh Beckman, MD. Neurosurgery One (Denver): I’m seeing increasing pushback from payers on several procedures we routinely perform in the ASC setting, particularly basivertebral nerve ablation, cervical disc arthroplasty and sacroiliac joint fusion. More recently, SI joint fusion has been especially challenging, even when my patients meet all the criteria. One of our patients was recently denied because they reported 70% pain relief from a diagnostic injection, rather than the 75% threshold noted in the policy. This kind of rigid interpretation doesn’t reflect how real patients respond to care.
These denials put us in a position where our clinical decision-making is constantly second-guessed by non-clinicians, even when it comes to deciding where a procedure should be performed. We know what’s best for our patients, and those decisions should be guided by medical judgment, not arbitrary benchmarks. My team and I are spending more time on documentation, appeals, and peer-to-peer reviews and taking time away from caring for our patients. Our workflow has had to change to stay ahead of denials to make sure every detail aligns with policy language and preparing for peer reviews early in the process. It’s frustrating, but it’s the only way to make sure our patients get the care they need in an outpatient setting when that’s what’s actually best for them.
Anthony Giuffrida, MD. Cantor Spine Center at the Paley Orthopedic & Spine Institute (Fort Lauderdale, Fla.): BVNA has been a target for persistent denials. Even when criteria are met, we’ve had to go through multiple rounds of appeals, and in some cases, present before administrative law judges just to get patients the care they need.
To stay ahead, our team is proactive. We’ve built out a structured preauthorization and documentation process that includes templated language aligned with each payer’s clinical guidelines. We also track which CPT codes trigger frequent denials and keep a rolling database of approval trends by carrier. On the backend, we’ve trained staff to flag downcoding patterns early so we can challenge it right away. It’s not ideal and very costly, but we’ve had to become part-clinician, part-claims specialist just to protect access to care.
Matthew Harb, MD. The Centers for Advanced Orthopaedics (Washington, D.C.): As an orthopedic joint replacement surgeon, I perform a high volume of hip and knee arthroplasties at ambulatory surgery centers. While many primary joint replacements are now approved for outpatient settings, procedures like revision total hip and knee arthroplasties remain on Medicare’s Inpatient Only (IPO) list. This creates significant barriers when attempting to transition these cases to the ASC setting.
As surgical techniques, anesthesia, and recovery protocols continue to improve, we’re seeing excellent outcomes with select revision procedures performed safely in ASCs with same-day discharge. These cases often offer cost savings of four to five times compared to hospital inpatient care. However, we face persistent challenges with payer approval, particularly due to:
- Inpatient-only status under Medicare, which precludes ASC or outpatient billing.
- Limited reimbursement to facilities, especially when complex revisions require more expensive implants.
- Frequent denials, prior authorization hurdles, and down coding from commercial insurers who often follow CMS policy closely.
To respond, our team proactively engages with payers through:
- Thorough documentation of medical necessity
- Preoperative peer-to-peer reviews
- Working with our ASC partners to negotiate case-by-case approvals
- Collecting outcomes data to support future policy advocacy
As value-based care and cost transparency continue to gain traction, I believe we’ll see growing support for transitioning complex joint procedures — when appropriate — to the outpatient setting. But until CMS removes key revision codes from the IPO list, these cases will remain difficult to authorize for Medicare and by extension, many private payers.
Saqib Hasan, MD. Golden State Orthopedics and Spine (Walnut Creek, Calif.): I am trying to transition the majority of my cases to the surgery center. Some of the best surgery center cases include standalone L5/S1 anterior lumbar interbody fusions or lateral interbody fusion for adjacent segment degeneration. These patients typically go home the same or next day in the hospital. As of now, the anterior interbody fusion code does not get reimbursed in a surgery center setting, while posterior fusion does.
I believe this is nonsensical, as these procedures have recovery profiles that make them ideal for an ASC.
Lali Sekhon, MD, PhD. Spine Surgeon at Reno (Nev.) Orthopedic Center: We have had great difficulties in getting major players to give reasonable or any contracts for TLIFs in the ASC. My suspicion is there is hospital interference as spine surgery is a cash cow for hospitals and this collusion is happening without a paper trail. When it’s cheaper and it’s better for the patient the contracting difficulties should not be there. Hospital systems saw a major exodus of orthopedics and are trying to stop the same in spine which will happen regardless over time.
