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Old 10-29-2011, 08:51 PM
Slackwater Slackwater is offline
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Default 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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Old 10-29-2011, 09:05 PM
Slackwater Slackwater is offline
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Quote:
Originally Posted by Slackwater View Post
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
Same Abstract/Poster, #65, the web page text did not include the adobe flash text which is re-typed below.

Patient Examples
A 39 y/o male dairy farmer presented with discogenic back pain that he had for about 13 years but worsened over the last year. He also had developed bilateral S1 radiculopathy. His MRI demonstrated disk degeneration at L3-4, L4-5, and to a greater degree at L5-S1. A discogram demonstrated a chemically and mechanically sensitive disk at L5-S1. After thorough discussion with the patient, he elected to proceed with arthroplasty at the L5-S1 to preserve motion to prevent further degeneration at the L3-4 and L4-5 levels. This was denied by his insurance carrier. A request for a ALIF was also denied. After eight months of working with physical therapy during the appeal process to the insurance carrier, the patient elected to proceed with a bilateral L5-S1 laminectomy to decompress the S1 nerve roots to alleviate the radicular pain. One month postoperatively he continues to have a right S1 radiculapthy and discogenic back pain.


A 22 y/o male presented with a five month history of low back pain. In addition he had bilateral S1 radiculapthy. His MRI demonstrated a L5-S1 single level disk degeneration. He underwent discography which demonstrated a mechanically sensitve disk at the L5S1 level. After thorough discussion with the patient he requested to prceed with a L5-S1 ALIF procedure. His insurance carrier however denied the request. During the appeal process however it was determined that even though he did not meet the carrier's requirements for an ALIF, he did meet the requirements for for arthroplasty at the L5-S1 level. The patient then underwent an arthroplasty, five months after presenting to the neurosurgery office. One month postoperatively he has significant relief of his back pain but is still bothered by left S1 radiculopathy.
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