Milliman guidelines, fusion, and ADR

[laid up doc]

It has been noted by myself and a few others (particularly Shay) that insurance companies are starting to deny fusions for discogenic pain/DDD... basically only covering it for tumors/infections/severe sponydylolisthesis.

At the same time, many will not cover ADR's, and while some will cover the only FDA approved lumbar device... some will not, and said lumbar device is not appropriate for all patients (for example: metal allergies, design possibly suboptimal for L5/S1). Then there are people with facet issues... who in some cases get worse after ADR.

I recently had a conversation w/ a pain colleague of mine... and in the coming years, it will only get harder to have ANY surgery covered for back pain that isn't due to the above factors.

The sad truth is that US spine surgeons have made their bed... some of their colleagues will and have operated on patients inappropriately. The literature on determining who will or won't do well with surgery is vague and hard to apply to individual patients. Even new research continues to have such vague inclusion criteria that it will be hard to determine which of many subsets of patients will benefit from any treatment (see my comments about stem cell trials in Cutting Edge section).

The bottom line is that things may get worse before they get better. Unfortunately coverage continues to vary by insurer - and most of us don't pick our insurance -- our employer does. I am very fortunate in that I was able to seek treatment overseas, and in that research in spine devices continues despite the draconian ways of the US. They are starting to not even bother to bring their devices to the US, because it is cost prohibitive. Everyone loses when a device isn't subject to the rigor of the FDA... but part of the problem is our litiginous society.

ok, my rant is over. just wanted to share what i do know and my best advice is.... save your $$. you may need it to pay for a procedure here or abroad if things continue as they are.