Why Isn’t Lumbar Disk Replacement Covered in Alabama?

Mar 13, 2023 at 07:56 pm by kbarrettalley

By Jane Ehrhardt

Currently, although BlueCross BlueShield of Alabama covers cervical disk replacement, the insurer does not reimburse for a lumbar total disk replacement (TDR). “Their guidelines still say it’s experimental, even though it’s one of the most studied topics in spine,” says Mark Prevost II, MD and orthopedic spine surgeon with Southern Orthopedic.

Last year, Aetna faced a 239-patient class action lawsuit over their lapse in coverage for lumbar disc replacement, having deemed the procedure as “experimental and investigational”, according to Becker’s Spine Review. They settled that suit in December. In other states, BlueCross entities have already approved the procedure. “It’s not ‘if’ it’s going to happen here, too, but when it’s going to happen,” Prevost says.

During his fellowship at Texas Back Institute, which celebrated their 3,000th lumbar disk replacement over a 20-year span, Prevost estimates that he completed around 100 disk replacement procedures. He returned to Birmingham to practice four months ago. “Thankfully, we can do cervical disk replacements here in Alabama,” he says. Last week, his most recent cervical disk replacement patient came in for her six-week follow-up. She presented with no neck pain, no arm pain, and was granted no restrictions.

Both surgical options have been around for nearly 20 years. Approved by the FDA in 2004, the biggest advantage for patients with lumbar TDR versus fusion is the preservation of motion in the disk. “If you keep motion, then you’re not stressing the level above and below,” Prevost says. “This helps prevent further need for surgeries down the road. For lumbar disk replacement, a very small percentage of patients -  roughly one percent - need an additional surgery, which you’d think insurance would like.”

Prevost has four patients awaiting BlueCross special approval for lumbar TDR, all between 27 to 35 years old. “The 27-year-old can’t play with her kids,” he says. “I could do a fusion right now, but the adjacent level gets stressed when you do a fusion, so there’s a high likelihood she will need another surgery down the road.”

In 2008, the Harrop study of lumbar disk replacement data found that in over three to 22 years of follow-up, nine percent of disk replacement patients developed ASD versus 34 percent in those who had lumbar fusion. Four years later, a study published in the International Journal of Spine Surgery mined charts of 1,000 lumbar disk replacements, and found only two percent resulted in reoperation for adjacent segment degeneration (ASD).

Cervical disk replacements had similar results, according to a 2019 meta-analysis in the Journal of Spine Surgery. Though ASD was similar in the short-term, at five years out to seven years, 4.3 percent TDR required reoperations versus 10.8 percent who had fusions.

A new study published in Spine compared data on cervical disc replacement to anterior cervical fusion gathered between 2008 and the end of 2009. It included 6,635 fusion patients and 327 disc replacement patients all covered by various Blue Cross entities. After three years, 10.5 percent of the fusion patients required reoperations compared to 5.7 percent for those with TDRs.

They found that not only had disk replacement saved on further surgeries, but the initial surgeries, along with the 90-day expenses, cost almost $5,000 less for the TDR group. The insurers had paid out $34,979 for the disc replacements compared to $39,820 for the fusion patients.

Part of the savings on TDR may be caused by the discrepancy in the fee paid to the surgeons. Right now for a cervical total disk replacement in Alabama, BCBSAL pays surgeons 24 RVU (relative value unit) versus 41 RVU for fusions. “The time for the surgery and the risk for the surgery are fairly equal,“ Prevost says. “Fusions may have to at times handle greater arthritic degeneration, adding on another 10 minutes or so. So it’s a relative similar time for almost half the payment.”

This could also play a small part of why Alabama orthopedic surgeons are not pushing more for lumbar disk replacement coverage, along with producing the same level of short-term relief to those in constant pain. “And it can be tough to get a doctor to change to what they’ve been doing for 20 years,” Prevost says. “But I don’t think it’s fair for patients to continue suffering when there’s a procedure available with hundreds and hundreds of articles that prove it’s better.”

Prevost thinks the approval by BCBSAL for lumbar disk replacements will come, but with his past experience with its outcomes, it can’t come fast enough. “It’s just a matter of time,” he says. “But that’s not helping patients now.”

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April 2024

Apr 23, 2024 at 10:42 am by kbarrettalley

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