Artificial disc replacement reached a milestone in December 2022 when Aetna settled a 239-person class-action lawsuit over its coverage of lumbar spinal fusion. By settling, insurers can no longer use "experimental and investigational" as a reason to not cover artificial disc surgery.
With the court victory in place, many spine surgeons are awaiting changes to Aetna's policy regarding disc replacement.
Aetna, in a statement to Becker's, said the clinical policy for intervertebral disc prostheses (CPB 0591) is under review and expects any updates to be made in February.
Here is what six surgeons told Becker's they want for total disc replacement coverage going forward.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
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Editor's note: Responses were lightly edited for clarity and length.
Question: Now that Aetna settled its total disc replacement lawsuit, what changes do you want to see from them and other payers?
Harel Deutsch, MD. Rush Medical College (Chicago): In 2021, Aetna was ordered to face a 239-person class-action lawsuit related to its coverage lapse for lumbar disc replacement. Aetna denied coverage of artificial disc replacement, reasoning that it is "experimental and investigational." Aetna settled the case. There has been a general trend for insurances to increasingly cover total disc replacements, and I think the case will greatly accelerate reimbursement for artificial lumbar disc replacement by all payers.
Brian Fiani, DO. Weill Cornell Medicine/NewYork-Presbyterian Hospital (New York City): Aetna reached a settlement with Brian Hendricks and Andrew Sagalongos on a 239-person class action lawsuit for which Aetna denied coverage for lumbar artificial disc replacements claiming they were "experimental and investigational" despite being FDA-approved by at least one company since 2006. I am a strong advocate for motion-preserving instrumentation.
Payer coverage policies should all be finalized soon going forth and be reasonable. I would like to see those policies have inclusive indications that help patients receive the treatments they need and the adequate reimbursement fee to the performing surgeons. I would also like to see payer policies include multilevel coverage.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: It is only a matter of time until payers will need to accept the cervical and lumbar arthroplasty are accepted treatments for spinal disc disease. This market has been around for almost 20 years, and it is not "experimental." I foresee the payers creating new and decidedly unimaginative ways of not paying for these surgeries. One thing I have noted is that their peer reviewers have become more dug in when denying prior authorization, even using their own criteria. So, while their policies will cover the surgery, they just will not pay. It is only with the strength of our patients and empowering their voices can we leverage the subscribers over the insurers.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Unfortunately, the prior authorization has become somewhat of a cat and mouse game, with insurance companies enacting ever increasing barriers to approval for surgeons and surgeons having to find ways to overcome those barriers. It seems the hope is that with more and more barriers, surgeons will give up trying to get a case authorized. However, the goal of reducing overutilization is not being achieved this way. The only thing this is achieving is delaying care, in some cases delaying care for cases which are truly necessary. We need better agreement on standards and appropriateness criteria between insurance companies, surgeons and physicians, and health systems, for spine surgeries and interventional procedures. These need to be uniform and transparent. These need to be standardized. This is the only way we can bring American spine care into the 21st century.
Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): I hope that more insurance carriers will acknowledge and accept spinal disc replacement as one form of standard of care in appropriate patients. We still must meet all their criteria to be able to get coverage. Some other insurance carriers will likely look to "beef up” their guidelines to prevent the class-action lawsuit. The true challenge is the patients who need more than two levels of surgery as the insurance companies look at "hybrid" as an experimental treatment. Overall, this is a small step in the right direction.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Unfortunately, this time lapse in legal decision and the 20-year run-up to performance, the industry may have to restart the use and indications of this technology. Current surgical approvals through insurance mandates and restrictions may add to the already lengthy wait times. Cautious optimism once again.