Prior authorizations for adult degenerative spine disease patients led to delays in care without improving costs, according to a study from the OrthoCarolina Research Institute team.
The study led by Rob Turk, MD, and Brad Segebarth, MD, looked at the charts of more than 7,000 patients recommended for elective surgeries at a private orthopedic group, according to a March 2 news release from the AAOS. Cases from January 2021 to December 2024 were included.
Six things to know:
1. Insurers denied coverage for 460 patients, nearly 7% of all included.
2. Most of the denials were for stand-alone lumbar decompression (15.4%) and lumbar decompression with instrumented fusion (27.8%).
3. In 138 cases, coverage was denied due to a lack of documentation of six weeks of physical therapy. In 122 cases spine surgery was deemed not medically necessary by the insurer.
4. Among initial denials, 142 needed a peer-to-peer appeal.
5. After initial denials, 142 of the patients had their surgery. The average delay time was 15.7 days.
6. “Patients had to live with the pain that restricted their work, family and community activities,” Dr. Turk said in the release. “Health plans continued to pay for ineffective care instead of approving procedures that could have helped much sooner. Additionally, our findings suggest that PA is likely to delay care and increase costs for patients, physicians and the overall health care system.”
