152. Comparison of current health insurance provider criteria for coverage of lumbar discectomy procedures

BACKGROUND CONTEXT Lumbar laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc (CPT code 63030) is a common elective procedure performed by spine surgeons. While clinical indications vary from surgeon to surgeon, The North American Spine Society (NASS) has published surgical indication guidelines for these procedures. However, health insurance carriers and health consulting firms have also developed their own guidelines regarding the same procedure. Each insurance carrier has its own vetting process for developing guidelines and then using these guidelines to approve or reject coverage for patients who undergo procedure code 63030. PURPOSE The purpose of this study was to assess the surgical indication guidelines published by health insurance carriers with the largest market share in the United States for procedure code 63030 and to compare them to the NASS guidelines. STUDY DESIGN/SETTING Not applicable. PATIENT SAMPLE Not applicable. OUTCOME MEASURES Not applicable. METHODS The top ten insurance carriers in the United States were selected based on their national market share value. A web search was utilized to identify the elective surgical coverage policies for each company. Guidelines for emergent procedures indicated for cauda equina or spinal cord compression were excluded from our analysis, as were the guidelines for other means of microdiscectomy including percutaneous and laser techniques. Policy guidelines were reviewed and compared for surgical indication criteria including symptoms, physical exam findings, imaging, nonsurgical management modalities and duration of nonsurgical management. RESULTS The 10 largest insurance carriers in the United States queried were found to hold 51.8% market share. Only 60% of the companies evaluated had clear surgical guidelines accessible on their websites. Of these groups, 67% percent used guidelines purchased from either MCG or eviCore (health consulting firms) and 33% published their own guidelines. All guidelines required a physician to report subjective symptoms of lumbar radiculopathy. However, only 67% of guidelines required objective physical examination findings. Preoperative neuroimaging with MRI/CT was required in all guidelines. Only eviCore specified that the images must be performed within 6 months of surgery. Also, only eviCore required lumbar radiographs to be performed preoperatively. Of carriers, 83% required at least six weeks of failed nonsurgical management with analgesics, physical therapy and/or steroid injections, while one carrier required12 weeks. There was no consistency in the number of attempted nonsurgical modalities. CONCLUSIONS This study demonstrates that 40% of queried insurance carriers do not readily provide their surgical guidelines on the internet. Of the available guidelines, there is an alarming amount of variation among insurance carriers used to determine coverage of procedure code 63030. No carrier had guidelines entirely consistent with NASS guidelines. Patients, and their doctors, have a right to know the details of coverage when making informed decisions about surgical procedures. Our data suggests that further study is warranted to look into these discrepancies in coverage. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.