'The devil is in the details': What's next for total disc replacement coverage


Aetna has settled a class-action lawsuit regarding its artificial disc replacement coverage, and spine surgeons have their eye on the insurer's future policy shift.

The 239-person class-action suit, which was filed in 2019 and brought forward in 2021, concerned lumbar disc replacement. While the FDA approved lumbar disc replacement for decades, Aetna's policy still labeled it as "experimental and investigational."

Scott Blumenthal, MD, of Plano-based Texas Back Institute, was the first surgeon to perform an artificial disc replacement in the U.S., and he said he felt the outcome was "inevitable" based on a similar case involving Blue Shield of California.

Now, Dr. Blumenthal is awaiting the changes that Aetna will make following the settlement.

"The devil is in the details," Dr. Blumenthal told Becker's. "They're not going to have a coverage policy for a couple of months because they'll take their time and develop a specific coverage policy … [Outside agencies] may say you have to cover it, but they may make up their own exclusions. If they stick to the FDA, then that's pretty reasonable. The FDA now has two level approval and one level, so we'll see if they cover two levels. It's all in the details of how they specifically write their coverage policy."

Richard Guyer, MD, another spine surgeon at Texas Back Institute lauded the settlement. 

"This is a great win for our patients as Aetna was the last major insurance company not to approve lumbar disc replacement," Dr. Guyer told Becker's. "It is just too bad that so many patients who were candidates for disc replacement were denied this treatment and many may have been forced to have fusions."

At Texas Back Institute, Mr. Blumenthal said he expects the settlement to open up opportunities for patients.

"We've got dozens of patients just at TBI that we're holding off based upon the fact they were on Aetna and even had very straightforward on-label indications," he said. "I think there will be a backlog, so it's just a matter of when [Aetna's] official policy goes into effect."

Aetna didn't immediately respond to a request for comment from Becker's.

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