Criteria for microdiscectomy coverage inconsistent, restrictive, study finds


Insurance criteria for microdiscectomy sometimes varies from the North American Spine Society's qualifications for medical necessity, according to a study in the International Journal Spine Surgery.

Researchers did a cross-sectional analysis of U.S. national and local insurance companies for lumbar microdiscectomy coverage policies, according to the study published in the February 2024 issue of the IJSS. Preapproval criteria were consolidated into four main categories: symptom criteria, examination criteria, imaging criteria and conservative treatment.

The study assessed 13 insurers that equated to about 31% of the market share in the U.S. Descriptions of symptom criteria, imaging criteria, and the definition of conservative treatment had "substantial differences" compared to what NASS determined.

The study concluded, "Although a guideline to establish medical necessity was developed by NASS, many insurance companies have created their own guidelines, which have resulted in inconsistent management based on geographic location and selected provider."

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