Last week the North American Spine Society released coverage policy recommendations for spine care treatments, procedures and diagnostics. Here are five things to know:
1. Recommendations on the first 13 procedures are published online and include:
• Cervical artificial disc replacement
• Endoscopic discectomy
• Epidural cervical injections
• Interspinous device without fusion
• Interspinous fixation with fusion
• Laser spine surgery
• Lumbar artificial disc replacement
• Lumbar discectomy
• Lumbar epidural injections
• Lumbar fusion
• Lumbar laminectomy
• Percutaneous thoracolumbar stabilization
• Recombinant human bone morphogenetic protein
2. NASS plans to release additional coverage policy recommendations for treatments, imaging and surgical augments in the near future, including cervical laminectomy and laminoplasty, facet joint blocks, radiofrequency neurotomy, DNA-based scoliosis test, minimally invasive lumbar fusion, percutaneous laminectomy and sacroiliac joint fusion.
"Our intention is multifold," says Christopher Bono, MD, NASS second vice president, chair of the Coverage Task Force, and chief of the orthopaedic spine service at Brigham and Women's Hospital in Boston. "We want surgeons, patients, insurance companies and other stakeholders to be able to access these coverage policies. When insurance companies deny these procedures, patients and surgeons can utilize these documents to show that treatment is in fact reasonable."
3. Spine surgeons across the country are experiencing more denials today than in the past and spending more time justifying their recommendations to insurance companies before the procedures are ultimately approved or denied. Insurance companies have changed coverage policies over the past few years as well to deny procedures previously covered or make it more difficult to obtain coverage. That's a key reason why NASS began to develop their coverage policy recommendations.
"We as a collective group decided we needed to do something beyond responding time after time to insurance company policies," says Dr. Bono. "Our reimbursement committee was a reactive committee. We sent the same responses when new policies would come up that weren't based on evidence but instead cited on references such as the Milliman guidelines. We decided we could do better."
4. Dr. Bono was selected to chair the committee and built its membership from scratch. He recruited volunteers from all specialties in spine and solicited coverage recommendation drafts from committee membership. All coverage policy recommendations went through a rigorous review process by operative and non-operative specialists before they were published.
"There is a committee with the sole purpose of reviewing the recommendations, and it's 100 percent a multidisciplinary committee," says Dr. Bono. "When we were coming up with the lumbar fusion policy, we received great input from our non-surgical colleagues. If there was a tendency to be too much in favor of surgery, that would be in-check; likewise for the injection policy and our non-operative procedures. It was a really well-balanced group."
5. The recommendations are based on the results of strong studies and cite much of the most recent findings in the field. UnitedHealthcare has acknowledged these recommendations and expressed interest in using them in their entirety or in part to develop coverage policies. Dr. Bono sees the recommendations having the biggest impact in promoting high quality spine care and improving utilization.
"We've taken the first step in developing and publishing the recommendations; now the product needs to be used," he says. "We need insurance companies to see these are evidence-based recommendations and fair coverage policies. We hope the insurance companies will adopt them. If they choose not to do that, practitioners and patients should put pressure on the insurance companies to adopt them."