Key thoughts on cervical disc arthroplasty coverage & payer policy

Spine

Two-level cervical disc replacement received a Category I CPT code in January 2015. Since then, the bulk of Blue Cross Blue Shield companies began changing coverage policies on one-level cervical arthroplasty.

"It has been a year of really positive changes for spine arthroplasty," says Kimberly Norton, vice president of healthcare policy and reimbursement at LDR Spine." We are starting to see coverage grow for this technology and become more accepted in the community. I believe it will become the gold standard in the surgeon community as well as the payer community, especially with one-level arthroplasty."

 

The North American Spine Society, International Society for the Advancement of Spine Surgeons and other professional organizations advocated for coverage and released coverage recommendations for both one- and two-level spinal arthroplasty, paving the way for coverage.

 

The inpatient DRG payment for cervical arthroplasty saw a 65 percent increase in 2015 over the previous year, adding to the momentum. "That signaled disc replacements are becoming more utilized and payers are starting to see the differential on what the procedure should be paid," says Ms. Norton. "Once it's used more in the outpatient setting, we'll see a similar move there."

 

Not all payers reimburse for cervical disc replacement in the outpatient setting yet, even if they do for inpatient procedures. Payers typically base coverage policies and negotiations on Medicare's policies, but Medicare doesn't currently cover cervical disc replacement. The best patients for disc replacements are often young patients — those with commercial insurance, workers compensation or personal injury.

 

"Commercial payers look at the Medicare DRGs and apply their own conversion factors," says Ms. Norton." As Medicare continues to look at the procedure, the outpatient setting opportunities will open up as they did with spinal fusion. There are some surgeons who perform the procedure in the hospital outpatient setting or ASCs currently based on individually negotiated contracts, which shows it can be safely done."

 

The literature proves one-level cervical disc arthroplasty achieves parity with spinal fusion in the outpatient setting. From a facility perspective, cervical disc arthroplasty is a well-paid procedure inpatient and outpatient. However, physicians are still paid more to perform anterior cervical discectomy and fusion than disc replacements.

 

"Over time the payment differential between arthroplasty and ACDF will have parity," says Ms. Norton. The discectomy and instrumentation are both included in the arthroplasty code whereas the ACDF code pays the device and insertion separately, accounting for the difference. However, medical societies and CMS have acknowledged the device and insertion will likely be bundled for spinal fusion codes in the future. "That might take a year or two, but we know with codes bundling for spine procedures we'll see the payments change."

 

She also sees two-level cervical disc arthroplasty coverage expanding in the future, faster than the one-level procedures. Researchers don't need to re-establish the groundwork for cervical arthroplasty's effectiveness — that foundation already exists with the one-level procedures — and can focus on building comparisons with fusion.

 

"We have superiority claims five years out for the two-level procedures," says Ms. Norton. "Instead of trying to figure out this new technology, the groundwork has been laid and I believe we'll see acceleration in coverage."

 

There are some payers, including United Healthcare and Medica in Minnesota with policies around two-level procedure coverage already. However, some payers report there isn't a high enough demand for coverage policies, so they don't develop them; at the same time, surgeons aren't performing two-level disc replacements because they can't obtain coverage.

 

"It's a bit of a circular argument," says Ms. Norton. "We are encouraging physicians to obtain preauthorization and then submit the claim. The procedure may need an appeal and the surgeon can share data with the payer about why disc replacements are a strong procedure. The payer may not have seen the newer data and the more physicians who put the information in front of the payer and demand coverage, the faster it will be covered. That's what it took for the single-level procedure."

 

Ms. Norton has seen an uptick in surgeons using cervical disc replacement as coverage improves. "We want the surgeons to understand that the coverage landscape has improved even from two years ago," she says. "When the payment between spinal fusion and disc replacement becomes more standardized I think we'll see disc replacements become fully accepted as the gold standard. Surgeons are making their decisions based partially on payments right now, and that shouldn't have to be part of their decision."

 

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