Spinal Fusion Reimbursement: Q&A With NASS President Dr. Greg Przybylski

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The number of spinal fusions has increased dramatically over the past decade and many insurance companies are tightening the indications for coverage of the costly procedure. Greg Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute at JKF Medical Center in Edison, N.J., and president of the North American Spine Society, discusses the controversy surrounding spinal fusions and the factors that impact fusion coverage.

Q: Why has there been so much controversy surrounding coverage for spinal fusions?

Dr. Greg Przybylski: From a national perspective, there has been a growing concern among third-party payors about the amount of money spent on spine surgery and spinal fusions are one of the more expensive procedures. If you look over the past 10 years, the growth in spinal fusions has been greater than the growth in decompressions. That doesn't tell us whether the change is appropriate or inappropriate, just that there's a change. The payors are looking at the reasonable and unreasonable indications for fusion in their coverage policies.

There are some things that we all agree on: fusion is appropriate in patients with fractures, dislocation, some infections and patients with cancer of the spine. The controversy surrounds patients with pain of an unknown origin and we assume it's coming from degenerative disc disease.

Q: How can surgeons distinguish whether the patient has DDD and whether they might benefit from a fusion?

GP:
Oftentimes, surgeons decide that a patient's pain is coming from DDD from a process of exclusion. In other words, we haven't found another source for the pain. As part of spine aging, discs degenerate and it becomes challenging to separate the normal aging affects of the spine from other things that are causing pain for the patient. Discography tries to gain insight into the disc and the source of the pain, but that isn't always the best test. We haven't quite achieved the technology to figure out which patients will have good outcomes from spinal fusions and which will not. When we look at what has been studied, there is a limited amount of information to guide us as to what predicts who will benefit or not benefit from fusions. Prospective randomized studies have shown mixed results: Some say there are better outcomes for patients who undergo surgery than those who don't undergo surgery; others say there isn't a difference in outcomes.

Q: Some insurance companies are beginning to deny coverage of spinal fusions for patients with DDD. What is the thought process behind these decisions?


GP: Insurers look at specific literature and they have become much more stringent in the studies they value. Prospective, randomized, double-blinded studies are they types of studies they are looking for and there are very few of these in spine treatment. This somewhat limits our ability to demonstrate through literature that there is evidence to support a particular indication for a patient. The push for further evidence has stimulated the spine surgery community to study additional indications that we don't have information for. Currently, third-party payors make independent decisions across the country and the professional societies have the opportunity to comment on them. Thus far, we have been fairly successful in modifying coverage policy. There have been some interactions we've had with third-party payors that demonstrate they are willing to listen and look at new and updated information and modify previous decisions they have made depending on what the data shows.

Medical associations also put out guidelines for procedures. These guidelines need to be revised at least every five years to incorporate new data and figure out where they might need to change. In the future, there's probably going to be a more critical look at the guidelines and further limitations sought after by third-party payors, but societies can defend a procedure based on the scientific data.

Q: How are the stricter guidelines for spinal fusions impacting spine surgeons?


GP: When one looks at the surgeon's practice, the impact revolves around patients with degenerative disc changes where they can't find another cause for their pain. If the patient has tried non-surgical methods, such as exercise, physical therapy, diagnostic and therapeutic injections, and those don't help, and the surgeon feels a fusion may benefit the patient, the insurer could deny the procedure in advance if the patient doesn't fulfill criteria for coverage. The surgeon may need to undergo additional leg work in developing a response or having a verbal conversation with the insurer's medical director to explain the unique circumstances in the patient. If that still doesn't work, the responsibility falls on the patient to appeal to the insurer for reconsideration of the treatment.

Learn more about the North American Spine Society.

Read other coverage on spinal fusions:

- ISASS President Dr. Thomas Errico: Spinal Fusion Update

- Spinal Fusions Face an Uncertain Future


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