Advocacy Alert: Changes to Spine Fusion Insurance Reimbursement Policy

Advocacy Alert: North Carolina-based SAS Members
November 15, 2010
Advocacy Alert: SAS Will Engage Payers on Spine Surgery-Related Procedures
December 2, 2010
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The SAS is alerting our membership regarding recent changes to a US insurance reimbursement policy covering spine fusion procedures. The revised policy may affect all SAS members, including international members, in the future. As past SAS President Chun-Kun Park, MD, PhD said:

“Such changes are likely to have an impact on the reimbursement policy quite a bit even in the other countries, because as you know, ‘bad news travels fast’ in the recent information society with advanced telecommunications. So, it can lead to a grave international issue.”

We want to bring your attention an issue that may adversely impact patient access to necessary spine fusion procedures: We have learned that North Carolina Blue Cross/Blue Shield Insurance (BC/BS NC) has issued a new, more restrictive policy for lumbar fusion procedures, effective January 1, 2011.

View the Policy Here (PDF) (Note: Policy document removed from BC/BS NC web site.)

Our initial read of this policy is that it is overly restrictive; specifically, there are several common scenarios where the standard of care includes fusion; however, this more restrictive policy may make it more difficult for those patients suffering low back pain due to spondylolisthesis to receive needed surgeries. These scenarios include:

  • Patients with degenerative spondylolisthesis who don’t have as much leg pain as back pain.
  • Patients with Isthmic Spondylolisthesis that is not progressive but nonetheless painful.
  • Patients where fusion for spondylolysis may be necessary/beneficial in situations where there is no slip and only back pain.
  • Patients where fusion is the only procedure that will relieve pain and immobility associated with degenerative disc disease, after 6 months of exhaustive conservative measures have failed.

Note that we have been in contact with both the AANS/CNS and the AAOS, in order to gauge their reaction to this policy. We have also reached out to our industry partners, including Medtronic, DePuy, Synthes, NuVasive, and Spinal Motion, and they plan to express their concerns to BC/BS NC as well. We have also established a dialogue with the NC Orthopaedic Society and the NC Spine Society, as well as the North Carolina Medical Society, and those organizations maintain a dialogue with the medical director of BC/BS NC, and will work with us on any direct communications in-state.

Our goals, therefore, are as follows:

  • Short term – develop a letter to BC/BS NC, outlining our concerns with specific provisions of this policy. It is our goal to do this in collaboration with any or all of the NC-based societies mentioned above.
  • Long term – SAS is in the process of developing a Position Statement on lumbar fusions that we can use in our advocacy efforts, and we welcome any clinical or scientific expertise that you feel may help us in this endeavor.

What we need from you:

We welcome your thoughts on the BC/BS NC lumbar fusion policy, and our intended course of action. Only through the shared insights and support of our members can we be successful in advocating for policies that provide patients with the appropriate access to surgical procedures that will improve their outcomes and quality of life. Please email your comments, concerns and suggestions to Kristy Radcliffe, Executive Director at kristy@isass.org.

We continue to identify and address on your behalf policies and actions that unnecessarily limit patients’ access to necessary surgical care, and welcome your input on any and all such efforts.

Regards,

Tom Errico, MD
President
SAS – The International Society for the Advancement of Spine Surgery