UnitedHealthcare to cover lumbar total disc replacement after patient forces 3rd party review

Written by Laura Dyrda | July 10, 2018 | Print  |

UnitedHealthcare issued a new positive medical policy for lumbar total disc replacement, covering single-level procedures for patients with degenerative disc disease.

 

The decision comes in the wake of a UnitedHealthcare member, Carrie Guthrie, fighting the payer's initial decision to deny her a lumbar total disc replacement with Aesculap's activL Artificial Disc. Ms. Guthrie was denied the procedure, but spent three months appealing the decision.

"I think my case was part of the change," she said. "When the activL Patient Assistance Line helped to get the approval of the lumbar disc replacement, I could not have predicted how the surgery would alter my life."

She underwent the procedure performed by Tapan Daftari, MD, of Resurgens Orthopaedics in Atlanta. During the external review process, UnitedHealthcare was required to send her case to an independent third party to determine medical necessity.

"UnitedHealthcare will begin covering [lumbar total disc replacement] because patients have helped them to see there is a demand for this procedure, and patients do well after receiving it," said Kim Norton, leader of Aesculap's payer policy and reimbursement efforts.

According to Aesculap Implant Systems President Chuck DiNardo, the company has invested in a payer policy strategy to obtain reimbursement for several procedures, including lumbar total disc replacement. Tricare and several Blue Cross Blue Shield plans have also recently updated their policy to approve lumbar total disc replacement coverage in certain patients.

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