'Its position has become untenable': Why 3 neurosurgeons are fed up with Aetna


While major insurer Aetna has taken steps to expand its coverage for spine and orthopedic care in the last year, for some surgeons, it's still not enough. 

In March, Aetna, which insures an estimated 22 million individuals, announced that it was expanding coverage to include Centinel Spine's Prodisc L lumbar total disc replacement system, which it previously considered "experimental and investigational." 

The insurer has also been wrapped up in a class action lawsuit over its coverage of lumbar total disc replacements. 

Three neurosurgeons — Luis Manuel Tumialán, MD, Praveen Mummaneni, MD, and Anthony DiGiorgio, DO — issued a statement to Becker's on their frustrations with Aetna and the fights many surgeons have been enduring with the insurer for years over a particular type of spine implant. 

Editor's note: Statement has been edited for length and clarity. 

"One commercial payer routinely frustrates spine surgeons performing anterior cervical discectomy and fusion: Aetna. During prior authorization, Aetna routinely denies coverage for interbody spacers in anterior cervical discectomy and fusion. Two decades of scientific research publications have documented the science of surface technology and osteoblastic ingrowth into biomechanical spacers. Yet, Aetna is the only major commercial insurer that deems the use of polyetheretherketone and metallic spacers as "experimental and not medically necessary" for routine ACDF.

"Curiously, Aetna has approved the use of these PEEK and titanium cages for cervical cases involving trauma or tumors, but not for degenerative disease. Aetna justifies this by saying spine cages are otherwise not considered medically necessary for cervical fusion because they have not been proven more effective than bone graft for this indication. Engaging in a peer-to-peer discussion about Aetna's denial of CPT code 22853 can be simultaneously frustrating and humorous. When the peer reviewer is a spine surgeon, there is typically a sympathetic ear but a helpless tone. They can't approve these cases, seemingly on orders from above. Comically, the peer surgeon may even suggest that patients delay surgery and consider switching insurance during open enrollment. 

If a spine surgeon reviewer does not conduct the peer-to-peer, the reviewer often fumbles trying to defend the policy without a genuine grasp of the research. The discordance of Aetna's coverage determination policy prompted the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on the Disorders of the Spine and Peripheral Nerves to write Aetna a letter questioning this ill-advised policy. The DSPN urged Aetna to reexamine and update its coverage determination policy so interbody cages can be an option for patients undergoing an ACDF. The DSPN highlighted the gap between Aetna's current coverage determination policy and the recently published literature, as well as the coverage determination policies of other major commercial payers (including United Healthcare, Blue Cross Blue Shield, Cigna and Humana). 

Every other commercial payer in the United States appears up to date and appropriately recognizes that an ACDF with a polymer or metallic interbody cage is scientifically sound and medically necessary. Strangely, there is no exception to Aetna's policy, even for patients who refuse allograft for religious or cultural reasons (e.g., Jehovah's Witnesses, Native Americans, Asian populations).

As it stands now, Aetna's position has become untenable. It seems solely financially motivated. Aetna's lone position on the 22853 CPT code has no other plausible explanation. The DSPN is asking that its members who serve on Aetna's scientific committee reconsider their role in this coverage determination policy that strips patients of their choices when undergoing an ACDF. Educational efforts are needed to inform patients that they and their surgeons cannot choose their cervical implants if they are insured by Aetna. That way, they can understand their options at the next insurance open enrollment period. It's time that Aetna puts patients over profits and provides our patients with the medical treatments that work best for them, not just the bottom line."

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.


Featured Webinars

Featured Whitepapers