Disparities Insurance Carriers, ALIF, PLIF, ADR/TDR : CNS 2010 Annual Meeting
2010 Congress of Neurological Surgeons
TITLE: Disparities between Insurance Carriers of Criteria for Approval of Lumbar Surgical Procedures: ALIF, PLIF, or Arthroplasty
AUTHORS: Timothy C. Ryken; Meleah Jensen
FINAL #: 65
CATEGORY: Spine/Peripheral Nerve
INTRODUCTION: Significant differences exist between insurance carriers, both private and government sponsored, for approval of various spine procedures. Attempting to meet the requirements for approval can be frustrating for both the patient and the surgeon. In addition, patient care is compromised when the recommended treatment is denied.
METHODS: Common insurance carriers for an Iowa neurosurgery practice were identified and contacted to determine coverage policy for anterior or posterior lumbar interbody fusion (ALIF or PLIF) or artrhoplasty. Each insurance carrier was also asked if they would disclose criteria to be met in order to obtain approval.
RESULTS:
It was determined that requests to government sponsored insurance carriers, Medicare and Medicaid, for spine fusion/arthroplasty are all addressed on a case by case bases that at times requires a long waiting period.
Of eight insurance carriers two carriers would approve ALIF/PLIFs but would not cover arthroplasty.
One insurance company would cover arthroplasty but only if certain criteria where met and not cover PLIF or ALIF for similar conditions.
One insurance company refused to detail their criteria for any lumbar surgery.
It was also found that insurance carriers would approve discography but would then not approve any spinal surgery if the study was positive.
CONCLUSION: Regardless of the recommendation of spinal surgeons for particular spinal procedures such as ALIF, PLIF or arthroplasty, ultimately the insurance carriers determine if the procedures will be carried out. There is non-uniform coverage for these surgical procedures as the insurance carriers policies currently stand. This can be detrimental to patient care as recommended surgery will be denied to the patient for non-medical reasons. Support for physician-generated evidence-based guidelines into the approval criteria for these procedures demands aggressive support of organized spinal surgeons.
KEYWORDS: spinal fusion, spinal arthroplasty, insurance, economics
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BTW: Please search for discography on adrsupport.org/forums if a surgeon suggests the procedure.
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