Cervical cage coverage: What to expect in the era of insurance company mergers

Written by Laura Dyrda | May 23, 2016 | Print  |

The International Society for the Advancement of Spine Surgery's policy statement on cervical cage coverage was published last year. However, insurance company denials continue to plague many surgeons across the country.

The CPT code 22551 was revised in 2011 to bundle CPT codes 63075 and 22554 when the procedures are performed at the same surgical site or during the same session with an add-on code to report additional interspace. The CPT code for cervical cages has had a higher reimbursement than structural allograft and insurance companies continue to say cages aren't medically necessary for the cervical fusion.

 

For example, Aetna changed its coverage policy after merging with Coventry in 2013 to state cervical cages are not medically necessary for cervical fusion except in multilevel corpectomy, discectomy or fusion for pseudarthrosis or to avoid more extensive dissection for plate removal in patients with adjacent level disease. At the same time, the FDA’s only on-label cervical cage use is in one- or two-level procedures; as a result, Aetna’s policy covers off-label but not on-label cervical cage use.

 

The payer policy changes coincide with a move toward value-based care, but just looking at the cost mechanism doesn’t constitute value. "In this case, the value is bogus. Neither the patient or the doctor receives any value in the exchange when alternatives are used," says Morgan Lorio, MD, of Bristol, Tenn.-based NeuroSpine Solutions. "The only person receiving any value is the insurance carrier. They restrict and ration what is included in the coverage."

 

Kern Singh, MD, of the Minimally Invasive Spine Institute and department of orthopedic surgery at Rush University Medical Center in Chicago, and Sheeraz Qureshi, MD, MBA, of the Mount Sinai Hospital department of orthopedic surgery in New York City, authored the ISASS policy. The statement recognizes anterior cervical discectomy and fusion as the gold standard for treating symptomatic cervical myelopathy and/or radiculopathy refractory to non-operative measures, citing research by Lee et al showing long-term success depends on arthrodesis as well as maintaining disc and foraminal height.

 

The statement also discusses pitfalls of the alternatives:

 

• Iliac crest autograft — morbidity at the donor site and lower fusion rates
• Structural allografts in conjunction with cervical plates — limited shapes and sizes as well as increased operative time to alter the allograft for the disc space

 

Surgeons are using synthetic structural grafts — cervical cages — to address issues with autograft and allograft. The synthetic grafts can be molded into different shapes and sizes for the surgeon to place a structural graft in the surgical space providing maximal endplate coverage and restoring focal and global cervical lordosis, according to the ISASS policy statement. Landriel et al shows in the article “Polyetheretherketone interbody cages versus autogenous iliac crest bone grafts with anterior fixation for cervical disc disease” achieving maximal endplate coverage can reduce subsidence for long-term correction of the disc space height and foraminal dimension. The synthetic structural grafts can be made from a variety of metal or plastic materials.

 

“It is important to consider that with the availability of improved intervertebral graft substrates, the surgeon’s work in performing a successful ACDF has increased. Surgeons who utilize cervical cages tend to perform a wider discectomy and more precise endplate preparation,” wrote Drs. Singh and Qureshi in the ISASS policy statement.

 

Cervical cages also make it easier for surgeons to take cases into the outpatient setting, which lowers the overall cost of care.

 

"The current cage construct has predictable geometries and characteristics," says Dr. Lorio. "Cages have transformed ACDF to an outpatient setting with diminished length of stay, subsidence and construct failure."

 

Insurance coverage could become more challenging with company mergers over the next several years. Last year Aetna announced plans to purchase Humana for $37 billion and Anthem planned to purchase Cigna for $54 billion. While executives from these companies report the mergers could “lower administrative costs,” the consolidation between large payers eliminates competition and could lead insurers to adopt the strictest policies available.

 

“Here in the U.S., with another round of mergers, this time Aetna with Humana and Anthem with Cigna, we are likely to see more coverage policies based on payers’ drive for profits instead of patients’ need for quality, medically necessary spine treatment,” wrote Dr. Lorio in the article “Caged in Denials” for the Spring 2016 issue of “Vertebral Columns.”

 

The anecdotal evidence is also apparent. Since the Affordable Care Act passed, Dr. Lorio has seen increasing denials and stricter definitions of experimental, investigational and medically necessary treatment.

 

"Patients often think if they have insurance they will be covered. They pay for coverage and think that's protection. But the insurance company could still deny treatment," says Dr. Lorio. Hospitals are also focused on value and limiting surgeons to one or two vendors, which may or may not include cervical cages.

 

"The value is to the hospitals and they are in some circumstances having surgeons sign product line agreements that restrict their language and even outcomes relative to the use of the select products," says Dr. Lorio. "The hospital might not even employ the surgeons but the surgeons still have to follow the rules.”

 

ISASS’s goal going forward is to give surgeons a voice and advocate for spine patients to access cervical cages for ACDF in appropriate cases. The organization hopes to form a coalition of spine partners to advocate for cervical cage coverage in the future.

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