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. Criteria for coverage include being 18 to 60 years old, having failed conservative treatment for at least six months, and confirmation of single-level disease through imaging.
This change comes just over two months after Aetna settled a 239-person class-action lawsuit calling out the insurer's coverage policy previously labeling lumbar disc replacement as "experimental and investigational." Lumbar partial disc prosthetics and multilevel lumbar disc replacement still have that label, according to Aetna's policy.
Jack Zigler, MD, a spine surgeon at Plano-based Texas Back Institute, told Becker's he was happy with the update.
"As a clinician intimately involved in the evolution of disc arthroplasty, it is gratifying to see that Aetna has finally recognized the value of lumbar disc replacement for the appropriately-indicated patient," Dr. Zigler said. "A strong database collected over the past 20 years has consistently demonstrated the value of this technology in improving outcomes in these patients over fusion or continued conservative care."
Scott Blumenthal, MD, who performed the first disc replacement in the U.S. at TBI, said while the update is important, he wished Aetna would follow other insurers and cover two-level lumbar disc replacement.
"I think obviously it's a good thing," Dr. Blumenthal said. "[The update] took way, way, way too long, and it's unfortunate that it took a class-action lawsuit to confirm what we have of 20 years-plus of really good science. I am disappointed that they ignored two-level lumbar disc replacement, which has just as good data. … [Aetna] wrote a very cookie-cutter, straight off the one-level trial criteria. What I found is there's a lot more gray-zone patients than perfect FDA trial patients, and it's going to be [important how] they enforce some of the gray-zone stuff."
Richard Guyer, MD, a spine surgeon at TBI, said the change was a long time coming as the practice enters its 23rd year of performing lumbar disc replacement.
"Now Aetna is almost on even ground with the other major insurance carriers but is still behind as many of them are now paying for 2-level lumbar disc replacement," Dr. Guyer said. "I feel most badly for those patients who were denied this treatment and ended up having fusion. We now consider all patients with degenerative disc disease as candidates for lumbar TDR and look for reasons why they may not be."
Jessica Shellock, MD, a spine surgeon performing total disc replacement at TBI, said the policy change would benefit patients' access to the procedure.
"It’s a shame that it took a class-action lawsuit to finally get this addressed but, at the same time, it shows that there is power when patients rally together and finally make their voices heard," Dr. Shellock said.
This article was updated Feb. 9 at 4:54 p.m. to include additional surgeon comments.