Spine surgeon sees TPAs reject procedures approved by insurer's policy

Laura Dyrda -   Print  | Email

Orthopedic and spine surgeons have watched the preapproval process become more rigorous over the past few years, and one reason is third-party administrators, said Scott Blumenthal, MD, partner at Texas Back Institute in Plano.

Insurance companies are increasingly using TPAs to process requests for surgery. One large insurer in Texas recently contracted with a TPA that denies prior authorizations for lumbar artificial disc replacements for patients who underwent previous spine surgery despite clinical evidence showing the procedure is effective for those patients.

"The insurance companies use TPAs because they have more restrictive policies," said Dr. Blumenthal. "They've come up with an exclusion for lumbar disc replacements that is anti-science because patients do well with this technology after a prior surgery. It was part of the indications approved in the FDA trial."

Dr. Blumenthal has had conversations with the payer about the denials, despite the payer's policies explicitly covering lumbar disc replacement for patients with prior surgery, but hasn't been able to reverse the coverage decision. He also spoke with the TPA, AIM, which continues to deny coverage through the peer review process.

This isn't the first time Dr. Blumenthal and his colleagues at Texas Back took on an insurance company's approval process. UnitedHealthcare previously developed policies for lumbar disc replacements that denied coverage for patients with prior surgery. Dr. Blumenthal, Richard Guyer, MD, and Jack Zigler, MD, conducted a substudy of the FDA study and detailed the results of patients with prior surgery in a letter to United. The results showed patients with prior surgery had better outcomes than patients without prior surgery.

"United changed their policy within months," said Dr. Blumenthal.

Anthony Romeo, executive vice president of the Musculoskeletal Institute of DuPage Medical Group in Downers Grove, Ill., had a similar experience with changing approval policies. He initially obtained preapproval for a patient's surgery, but after the patient was sedated, his office received a call from the insurer saying the code on the patient's prior authorization was wrong and it would no longer pay for surgery that day.

He had to conduct a peer-to-peer review to gain approval, which he did while the patient waited.

"They did have the wrong code. We changed the code, and I immediately got an approval reference number," Dr. Romeo said. "We went ahead with the procedure. That's crazy. That's not in the best interest of patient care, and taking [prior authorizations] too far."

Alok Sharan, MD, of NJ Spine and Wellness in East Brunswick, N.J., said the lack of consistent policies between insurance companies for prior authorizations and coverage casts doubt on the preapproval process.

"It is interesting to see the variability in medical guidelines among the insurance companies," said Dr. Sharan. "I've had instances where a patient was denied spine surgery by one insurance company. They enrolled in another insurance plan and were subsequently approved for surgery. This contradiction clearly is not good for delivering high-value patient care."

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