Some spine procedures including spinal fusion, lumbar decompression and vertebral augmentation will need prior authorization under CMS’ new Wasteful and Inappropriate Service Reduction model, a move worrying some surgeons.
The CMS model is targeting 17 procedures that were identified as being vulnerable to fraud, waste and inappropriate use.
However some spine surgeons say the move will only pose as another roadblock for physicians to treat patients.
Two spine surgeons shared their thoughts with Becker’s.
Note: Responses were lightly edited for clarity.
Grant Booher MD. Longhorn Brain & Spine (Fort Worth, Texas): CMS continues to make it harder for physicians to deliver timely, evidence-based care. Adding prior authorization requirements to procedures like cervical spinal fusion or epidural steroid injections — especially ones already governed by clinical judgment and imaging — only delays care, increases administrative burdens and worsens outcomes for patients in real pain.
CMS may claim it’s about value-based care, but it feels more like bureaucratic overreach. Spine surgeons aren’t ordering these procedures on a whim. We’re already held accountable by outcomes, documentation, peer review and lawsuits — now we have to fight with insurers and Medicare just to treat our patients?
It’s exhausting, it’s unnecessary, and ultimately, it’s the patient who suffers.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Like a lot of well meaning initiatives, this one is fatally flawed. First off, it assumes that cervical fusion is a source of major fraud. The null hypothesis that most spine surgery is unnecessary remains to be shown in any sort of large scale studies. While this model states that clinicians would be the final say so in whether or not a procedure is authorized or not. It is way too easy to flip that switch and offload that to AI.
A physician in front of a patient will always be the arbiter of what’s best. No machine, learning or algorithm will substitute for a review of a patient’s films, history and physical exam and making that final determination. We have numerous checks and balances on a local level where unnecessary surgeries are often fared out by morbidity and mortality.
While physicians are, of course, not above reproach for outcomes, it is still amazing to me that we think a person who never examined a patient or looked at their films or a machine for that matter can make a determination whether or not someone needs surgery. The hubris here is staggering.
Instead of investigating the Medicare advantage administrators for fraud and theft from American taxpayers and illegal uploading, it seems the physicians are still left holding the bag.
