The first in a two-part series on commercial insurance and artificial disc replacement surgery
Your health insurance policy covers treatment of illnesses, injuries and health conditions. When it comes to surgery, your health insurance provider may or may not cover the procedure or may place certain restrictions and requirements that need to be met before they approve.
Lumbar artificial disc replacement surgery is one of those surgeries that some carriers will approve and others will deny based on their criteria for what is a “medical necessity.”
For patients unclear about whether their health insurance carrier covers artificial disc replacement, a conversation with your doctor or health carrier about approval is the first step.
Once you and your doctor have eliminated conservative treatment methods, discussion about surgery will lead to a conversation about your health insurance. Your carrier will require prior authorization. Prior authorization requires your physician to get your health insurance provider’s approval before you can get artificial disc replacement surgery. Insurance carriers use prior authorization as a method to evaluate surgical options and minimize costs, especially in the case of expensive surgeries. Without prior authorization, you could be responsible for costs associated with your surgery should your carrier turn you down. Talk to your doctor or insurance carrier to find out what the requirements are for coverage. Depending on your health insurance provider, you could be denied coverage for a procedure or surgery if:
- The surgery is specifically not covered within your policy, or your insurance company has determined the treatment is not medically necessary.
- Your insurance company has determined the treatment is not medically necessary, or it does not have therapeutic benefits.
- Your insurance company deems the recommended treatment option to be experimental. This can be the case for procedures that involves new technology.
Presently, just over 80 health insurance carriers fully or partially cover artificial disc replacement on your low back. While insurance carriers are beginning to acknowledge that they need to cover this procedure – in fact now one in every two Americans have commercial insurance that covers this - it still leaves millions of patients in the balance.
Just because your doctor says that it is necessary doesn’t mean that your health insurance company will agree. This is why your doctor is tasked with providing documentation to your health insurance carrier to begin the approval process. Your doctor will be asked to present the severity of your back pain, failed treatment options and documentation about your skeletal maturity. It is then up to your health insurance provider to green light the surgery. In some cases, this doesn’t happen due to potential misconceptions about artificial disc replacement surgery.
Do’s & Don’ts of Pre-Authorization
If your health insurance plan requires that you have your procedure cleared by them first, heed the warning. Failure to get prior written authorization could leave you paying the complete bill with your insurer paying nothing. Here are a few additional tips:
- Don’t skip preauthorization. As mentioned, it could be financially devastating.
- Do make sure all of the paperwork is completed.
- Do know and understand what will be covered and what will not be covered.
From Misconceptions to Denials
A reimbursement executive at a spine device company, said, “There is an outdated perception among commercial payers that lumbar total disc replacement is not safe (early complications), not effective (early expulsions, unknown wear, no long-term data) and extremely expensive.
Right now, according to the reimbursement executive, many health insurance plans are requiring radiologic proof of instability with a trend toward referring prior authorization of spine surgery to radiology management companies. “Most payers are making you jump through hoops or follow stringent guidelines to get medically necessary cases approved. They delay or deny—deem the procedures as ‘elective surgery’— in order to save money,” the reimbursement executive says.
And while some health plans seek to find ways to explain away the benefits of artificial disc replacement surgery, for the millions of people living with back pain that can be corrected by the procedure, it leaves them in a frustrating conundrum: do I accept the outcome or file an appeal with my health care provider?
By law, an insurance company must provide its members with a reconsideration and review process when denying a claim.
In the second part of this two-part series, we’ll discuss what this process looks like and the process of filing an appeal for covering artificial disc replacement surgery.