Spine surgeons told Becker’s that insurers are increasingly asking for the exact graft and implant names planned for surgery before approving some spinal fusions, on top of level-by-level coding, imaging and proof of failed conservative treatment.
Getting a fusion approved increasingly depends on more than showing the operation is medically necessary. The requirements vary by insurer, but together they are creating what amounts to a more granular payer checklist before some fusion cases can move forward.
And the scrutiny is spreading. Traditional Medicare entered the equation in 2026 through CMS’ WISeR model, which includes cervical fusion among the services subject to prior authorization or pre-payment medical review in six states.
For hospital spine programs and surgery centers, the documentation burden shows up on the operations side: more staff hours per case building the authorization file, longer gaps between a surgical decision and a scheduled OR date, and revenue that sits unbilled until a payer signs off.
Every level may need its own justification
Brian Gantwerker, MD, president of The Craniospinal Center of Los Angeles, told Becker’s that insurers are increasingly asking surgeons to specify which CPT code corresponds to each operative level, which system will be used and whether patients have completed months of nonsurgical treatment.
“The new level by level requests” are among the requirements that have become more common, he said.
For multilevel cases, that can turn one surgical plan into several individual arguments for coverage rather than a single determination that fusion is appropriate.
Conservative care has to be documented, and in the right order
Failed nonsurgical treatment is not new to fusion authorization. Surgeons say the level of documentation surrounding it is.
Issada Thongtrangan, MD, an endoscopic and minimally invasive spine surgeon at MicroSpine in Scottsdale, Ariz., told Becker’s that some payers expect precise documentation of physical therapy duration and dates, medications, injections, patient-reported outcome measures, disability scores and imaging.
“Now, it’s not enough to be right,” he said.
Kasra Ahmadinia, MD, of Tulsa-based Advanced Orthopedics of Oklahoma, described a patient whose authorization process stretched nearly six months as the insurer required physical therapy, injections and waiting periods. By the time those steps were completed, he said, the earlier physical therapy was considered outdated and had to be repeated.
“The goalposts are moved all the time,” Dr. Ahmadinia told Becker’s.
The note has to speak the payer’s language
Clinical documentation itself is becoming part of the authorization strategy.
Bryce Basques, MD, director of minimally invasive and endoscopic spine surgery at Brown University in Providence, R.I., said insurer algorithms can search for specific terminology before a person reviews the case.
“Writing notes no longer means documenting medical decision-making,” Dr. Basques told Becker’s. Instead, he said, physicians increasingly have to satisfy algorithms with the appropriate words and phrases. He said an initial denial can arrive before human review, triggering appeals and peer-to-peer calls even when the procedure is ultimately approved.
Alex Vaccaro, MD, PhD, president of Philadelphia-based Rothman Orthopaedics, has described the broader tension similarly.
“Prior authorization has seemingly prioritized standardized rules and checklists over personalized care and patient-centered decision-making,” he told Becker’s.
Even the implant can be part of the approval
The scrutiny can continue after a payer accepts the need for surgery.
Jacky Yeung, MD, a neurosurgeon at Yale Medicine in New Haven, Conn., told Becker’s that authorization requests that once centered primarily on whether fusion was medically necessary can now ask for the exact graft materials and implant names the surgeon plans to use. He said the additional requirements can create delays even for FDA-approved devices with established indications.
Coverage rules can also influence the alternative to fusion. Lauren Matteini, MD, of Geneva, Ill.-based Fox Valley Orthopedics, told Becker’s that securing approval for cervical arthroplasty can be difficult in patients with a prior or congenital fusion, even when she believes preserving motion at another level is appropriate.
“There are a lot of insurance company red flags and red tape and hoops to jump through,” she said.
Medicare has joined the equation
The payer checklist is no longer exclusively a commercial insurance or Medicare Advantage issue.
CMS’ WISeR model began in 2026 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Cervical fusion is among the selected services reviewed under the model, along with epidural steroid injections, vertebral augmentation and image-guided lumbar decompression. Providers can seek prior authorization or have claims undergo post-service, pre-payment medical review.
CMS is using technology-enabled review under the model, although the agency says a clinician retains authority over adverse determinations. The program runs through 2031.
At the same time, some insurers are moving in the other direction. UnitedHealthcare recently said it will remove prior authorization for several spine surgery codes in Medicaid managed care plans across 16 states and Washington, D.C., effective Oct. 1, part of a broader effort to reduce its remaining prior authorization requirements.
The changes also show how authorization requirements can vary by payer, plan and procedure, even as some insurers move to reduce prior authorization for certain services.
For spine surgeons, that means the clinical decision to perform a fusion may still be followed by a separate process of meeting the payer’s documentation and coverage requirements.
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