Spinal Fusions Face an Uncertain Future


In December, Blue Cross Blue Shield of North Carolina announced beginning Jan. 1, the company would no longer cover lumbar fusions for patients with degenerative disc disease. This announcement hit a nerve with many spine surgeons who have been performing successful lumbar fusions on degenerative disc disease for the past several years, and many of them have joined in the advocacy efforts to reverse the company's decisions.

BCBSNC stated it will continue providing coverage for lumbar fusions in some patients, such as those suffering from spinal fractures with instability or neural compression and spinal tuberculosis. The lumbar spine fusion will not be covered for disc herniations, DDD, initial discectomy or laminectomy for neural structure decompression and facet syndrome.

Since the announcement was made, nine different orthopedic and spine societies have sent a letter responding to the BCBSNC's decision, recommending that the company continue to cover lumbar fusions for DDD, a procedure that has been standard among spine surgeons for the past 15-20 years. Surgeons don't recommend spinal fusions for patients on the initial visit, rather only after an extensive period of non-operative treatment fail to resolve these problems.

Since the new year, spine surgeons across the country are reporting denied claims and stricter rules for coverage of fusion surgeries.

The letter from orthopedic and spine societies
For the first time in history, the nine largest American orthopedic and spine societies, led by the North American Spine Society, American Association of Neurological Surgeons and the Congress of Neurological Surgeons, agreed on a concrete set of points on addressing the policies of an insurance company. While the letter applauds the goal of approving patient care through conservative methods, the societies expressed concern regarding the criteria guidelines and suggested specific modifications to the policy.

The letter was signed by the current presidents of all nine organizations. Those involved with writing the letter hope it will stimulate dialogue between insurance companies, major spine societies, spine surgeons and patients. There has been an influx in patient advocacy for rights to procedures in the recent years, as patients are becoming savvier about researching the different treatments for their conditions.

Evidence supporting spinal fusions for DDD
Beyond the history many spine surgeons have with performing lumbar fusions, recent studies, such as the SPORT trial, have shown the benefits of surgical treatment for spinal patients. The results from the trail for degenerative spondylolisthesis found that patients who were treated surgically showed more improvement in pain and function than the patients treated non-surgically. Degenerative disc disease occurs in patients who are at the end stages of degeneration.  When compared with degeneration of other joints, such as hips and knees, it is accepted that the hip and knee patients need to have surgery, while spine patients must go through several barriers before being approved for surgery.

If surgery isn't available to patients who experience pain relief from conservative methods, those patients are likely to need constant narcotics and are at risk for degenerating even further. Many state insurance companies have fairly restrictive policies for performing lumbar fusions, but sometimes when the procedure is appropriate, the letter argues surgeons and patients should be allowed to make the decision to undergo the procedure.

Spine surgery registries
An attempt to gather a national registry in orthopedics has gained serious ground this past year as a result of several issues, including hip replacement recalls. Professional spine societies are also researching the possibility of creating a large-scale spine registry, which could be used for data mining on successful or failed outcomes. Surgeons could use a spine registry to predict the outcome of surgery on similar patients, collect data for studies and literature reviews and to identify complication rates among individual surgeons.

A registry of surgeon outcomes could track patients after the fusions and see how many complications and further operations they need. This process would identify the surgeons who are best at performing a specific procedure. Profiling of spine surgeons could be controversial, but it is one way to ensure that only surgeons who have the best outcomes for specific procedures are performing them. Insurance companies and patients could benefit from this in the long-run because the surgeries done by these surgeons are more likely to have successful outcomes.

With the knowledge of outcome data for individual surgeons, insurance companies could steer patients toward surgeons who have good outcomes and away from those who don't. This competition could also encourage further technological advancements in spine surgery to create better outcomes.  

Read the North American Spine Society release on the letter to NC BCBS.

Read the NC BCBS policy (pdf).

Read the letter to NC BCBS on lumbar spinal fusion coverage (pdf).

Read other coverage on spinal fusions:

- ISASS Defends Spinal Fusions

- Spine Patient Outcomes Research Trial: Surgery Better for Appropriately Indicated Patients

- Report Investigates Spinal Fusions Performed By Twin Cities Spine Surgeons

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