Published February 28, 2013

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A collection of nine medical associations is arguing against new restrictions on spinal-fusion surgery set by a health insurer in North Carolina amid concerns such restrictions could limit patient care and spread to other states.

Whether the groups can alter the new rules from Blue Cross and Blue Shield of North Carolina, which go into effect Jan. 1, remains to be seen. But the response is evidence doctors are joining forces to battle ongoing insurance pressure on the spinal-fusion market. Several spinal device-makers, most recently NuVasive Inc. (NUVA), have cited signs insurers are raising barriers to such procedures amid concerns they're over-utilized. 

Doctors worry the new policy in North Carolina, which is seen as particularly restrictive, could further dampen an already slowed market if it spreads elsewhere. 

"We certainly see that once even a local area starts coming up with these policies, others may start adopting it," said Joseph Cheng, who directs the neurosurgery spine program at Vanderbilt University Medical Center in Nashville, Tenn. He also serves on the coding and reimbursement team for the American Association of Neurological Surgeons, which co-signed the letter. 

The letter was sent last week and also signed by the American Association of Orthopaedic Surgeons, the Scoliosis Research Society and the North American Spine Society, among other groups. They said they "have concerns regarding the criteria and guidelines" in the new coverage policy, and they proposed less restrictive language. 

That policy includes detailed descriptions of conditions for which fusion surgery in the lower back should and shouldn't be covered. In one case, the new policy denies coverage for patients with degenerative disc disease. There is also new requirement for prior authorization before patients get surgery. 

According to Lew Borman, a spokesman for Blue Cross Blue Shield of North Carolina, the new policy was reviewed with several spine surgeons before it was finalized. He also noted that it references several medical studies. The insurer responded to the letter from the medical associations in an email and plans to meet with representatives from those groups in January to discuss their perspective, Borman said. 

"We'll certainly hear out their concerns," he said. He added that it's too soon to speculate on whether any changes could be made as a result. 

Jefferies & Co. analyst Raj Denhoy said it's a good sign the doctors' groups banded together to raise issues with the North Carolina policy, which he called "probably the most restrictive that has been written thus far. 

"What has been missing from the dialogue on insurance push back of spine procedures is the clinical spine community's response," Denhoy wrote in a research note.


About Dr Kevin Lau
Dr Kevin Lau is the founder of Health In Your Hands, a series of tools for Scoliosis prevention and treatment. The set includes his bestselling books Your Plan for Natural Scoliosis Prevention and Treatment and An Essential Guide for Scoliosis and a Healthy Pregnancy, a companion Scoliosis Exercises for Prevention and Correction DVD, and the innovative iPhone and Andoid application ScolioTrack.

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