10 payer victories in 2023

Orthopedic

While orthopedic and spine surgeons continue to express frustrations with payers, complaining of low reimbursements and tricky prior authorization processes, there have been several small victories for surgeons in 2023. 

From expanded coverage to more procedures approved in the ASC setting, here are 10 payer victories for musculoskeletal specialists this year: 

1. Large commercial payers in Illinois, Texas, New Mexico and Oklahoma now cover one- and two-level lumbar disc replacement. Prodisc L is the only total disc replacement device approved by the FDA for two-level lumbar disc replacement. 

2. CMS added five orthopedic surgical codes to the ASC payable list for 2024, including incision of hip tendons and reconstruction of ankle joints. 

3. Relievant Medsystems' Intracept spine procedure earned a positive coverage policy from Anthem Blue Cross Blue Shield.

4. Premia Spine earned CMS' new technology add-on payment for the TOPS system. 

5. Centinel Spine's Prodisc device earned positive coverage by a large commercial payer in Michigan. 

6. Cigna implemented a positive coverage policy for Intrinsic Therapeutics' Barricaid bone-anchored annular closure device.

7. Cigna will now cover Relievant Medsystems' Intracept procedure for the treatment of vertebrogenic low back pain.

8. ZimVie's vertebral body tethering system for scoliosis received a positive medical policy decision from Highmark. 

9. Access to Centinel Spine's Prodisc L lumbar total disc replacement system is expanding as Aetna has updated its guidelines to include one-level lumbar total disc replacement in its coverage. Now, all major commercial payers cover one-level lumbar TDRs. Over 95 percent of U.S. patients are now covered.

10. Aetna updated its Clinical Policy Bulletin Feb. 8 following a class-action settlement related to its lumbar disc replacement coverage. The new review said FDA-approved total disc implants are "medically necessary" for treating lumbar degenerative disc disease at one level under certain criteria.

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