Documentation requirements and prior authorization for spinal fusion have become increasingly burdensome in recent years, prompting spine surgeons to spend more time meeting insurer documentation standards and appealing denials. Five spine surgeons discuss the administrative hurdles they say have emerged over the last five years and whether they improve patient care.
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Editor’s note: Responses were lightly edited for clarity and length.
Question: Documentation and prior authorization around spinal fusion keep climbing. What is the most maddening hurdle you clear now that didn’t exist five years ago, and what is it actually accomplishing?
Bryce Basques, MD. Spine Surgeon and Director, Minimally Invasive and Endoscopic Spine Surgery, Brown University (Providence, R.I.): The most infuriating hurdle is algorithmic, AI-based prior authorization that often differs based on the insurer. Writing notes no longer means documenting medical decision-making, but rather satisfying algorithms with appropriate buzzwords and phrases in order to get appropriate care for the patient.
Usually the first denial comes back before a human being has read anything, leading to a long wasteful process of appeals and peer-to-peer phone calls. All of this accomplishes nothing, because the surgery usually eventually gets approved anyways after significant delay and administrative burden.
Brian Gantwerker, MD. Neurosurgeon and President of The Craniospinal Center of Los Angeles: The new level by level requests, asking which CPT code corresponds to which level you are operating on, or which system you are using, or documenting six months of non surgical care, are all simply a shell game in what should be a reasonable ask on both parties.
Recently, I had an insurance company arbitrarily deny a patient who is 65 with normal bone density and artificial disc because their cutoff was 63. There was no peer-reviewed literature cited. That’s just how they felt that particular year. And so it goes.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): If I’m being honest, the most maddening hurdle right now isn’t just prior auth itself, it’s the layered documentation game you have to play to prove something we all already know is indicated. Five years ago, if a patient had clear instability, stenosis with spondylolisthesis, failed conservative care, you documented it and moved forward. Now, it’s not enough to be right. You have to tell the story in exactly the language the payer wants, check every box in their algorithm and often do it multiple times.
The part that really gets to me is the “fail-this-then-fail-that” sequencing with perfect documentation of each step: Physical therapy duration, with dates, medication trials, sometimes irrelevant to the pathology, Injections, even when you know they won’t change the outcome, PROMs, disability scores and imaging and wording that matches their criteria. If one phrase is missing or worded wrong, it’s denied, not because the surgery isn’t appropriate, but because it didn’t match their guidelines.
Then comes the peer-to-peer, which in many cases feels less like a clinical discussion and more like reading your note back to someone who already has a checklist in front of them.
What is it actually accomplishing? In theory, it’s about value, trying to avoid unnecessary surgery and standardize care. And to be fair, that’s not an unreasonable goal. There’s always been variability in spine surgery, and some guardrails probably make sense.
But in practice, a lot of this has turned into administrative friction rather than true quality control. You’re not being asked, “Is this the right operation for this patient?” You’re being asked, “Did you document it in the exact sequence we require?” The irony is, most of the cases that get denied initially end up approved after appeals or peer-to-peer. So we’re not really filtering out bad surgery, we’re just delaying good surgery. At the end of the day, it feels like we’ve shifted from practicing spine surgery to practicing documentation that justifies spine surgery. And those are not the same skill set.
Jacky Yeung, MD. Neurosurgeon at Yale Medicine (New Haven, Conn.): One of the most frustrating changes has been how much more granular prior authorization has become. In my experience, requests that once focused primarily on whether a spinal fusion was medically necessary now often extend to the exact graft materials and implant names that will be used, even when they are FDA-approved devices with well-established indications.
While appropriate oversight is important, these additional administrative requirements add delays and consume valuable clinical time without clear evidence that they improve patient outcomes or safety. It often feels like an extra bureaucratic hurdle rather than meaningful quality assurance.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): All of us continue to practice within the boundaries of insurance scrutiny, therefore our complex spinal practices are much accustomed to the ever-growing appeals processes for fusion procedures. Comparing this practice to other members of our institution, we have less peer-to-peer interrogatives, which is causally based on patient complexity and submitted requisition.
Documentation including detailed history and physicals, radiologic reporting and itemized imaging are collectively sent upon surgical agreement with both patients and families. In cases of controversy or chronicity, correlative data sets of exhaustive conservative measures and symptomatic parallels with radiologic modality are set forth, so that fray and conflict are avoided.
There are a number of insurers who certainly stand out amongst others concerning denials and peer-to-peer as the routine, yet these circumstances, and the respective expectation, require no more than a conversation and relative installment. In most occurrences, these interactions are a formality and are settled within that instance. With the persistent surgical demand for unnecessarily large procedures, the forbearance of this surveillance is completely understandable by this practitioner.
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