Spine surgeons' next payer battle

Spine

Spine surgeons saw a major victory in a yearslong payer battle this year when Aetna revised its lumbar disc replacement policy in February. Now, some surgeons are looking ahead to the next hurdle they could face from insurers.

Endoscopic spine surgery, a minimally invasive technique, has grown its reach in the U.S. in recent years. But it's seeing some resistance, Michael Gallizzi, MD, said.

"Payers currently pose a significant barrier," Dr. Gallizzi, of the Steadman Clinic in Vail, Colo., told Becker's. "Some states strongly oppose the adoption of this technology on the payer side, even though it's an approved Medicare procedure."

However, Dr. Gallizzi didn't think conflicts with payers and endoscopic spine would mirror those of disc replacement.

"I believe that part of the issue with disc replacement in the neck and lumbar spine arises from the fact that it involves an implant rather than a technique or technology," he said. "Because it's an implant, payers are often reluctant to cover something that's expensive. Conversely, adopting these tools and performing procedures in this manner usually falls under the category of equipment, typically the responsibility of hospitals."

Saqib Hasan, MD, of Walnut Creek, Calif.-based Golden State Orthopedics and Spine, said he's encountered challenges with the current coding for the technique.

"The coding of spinal endoscopy is premature and inconsistent," Dr. Hasan said. "The early use of endoscopic procedure codes were conflated with percutaneous procedures performed by non-spine surgeons. The lumping of apples and oranges resulted in an inaccurate reflection of the true value of the work inherent to full-endoscopic spine surgery. The key distinction between percutaneous spine procedures is that endoscopy utilizes direct-light based visualization of anatomy, akin to using a microscope and a tube — just on a miniature scale. Hence, coding should reflect that. Payers still sometimes deny these procedures as 'experimental,' despite some of the best randomized controlled studies in spine surgery affirming their benefits and at minimum, equivalence in outcomes."

Robert Rothrock, MD, director of spinal oncology at Miami Neuroscience Institute said the word "experimental" was a frustrating description of endoscopic spine.

"When you say 'experimental,' to a surgeon, we have a very guttural response to that. Because [this technology] is not experimental," Dr. Rothrock said. "We're not experimenting on our patients. The [insurance] industry has termed it experimental because they don't feel they have sufficient long term outcomes data."

Dr. Gallizzi, Dr. Hasan and Dr. Rothrock all emphasized the importance of research and gathering data for endoscopic spine surgery to help improve payer interest and reimbursements. 

"The onus is on us as a community to perform research that is credible and ethical, such that we perform evidence-based surgery," Dr. Rothrock said. "My attitude is that there’s enough of a foothold in the community of spine surgeons that I think [reimbursements] will get there, and that's why I'm more positive about it."

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