January 26, 2010

On January 20th, SAS President Tom Errico and leaders from eight other professional spine societies met with the medical leadership of Blue Cross & Blue Shield of North Carolina (BCBS-NC) to discuss the spine community’s concerns with a newly published BCBS-NC policy on lumbar fusions. The posting of the policy by BCBS-NC last fall prompted an outpouring of concern that its restrictive nature would limit or deny surgeries for patients in need, and that several conditions and diagnoses previously necessitating surgery would not be covered under the new policy.

In late December 2010 the spine community came together to draft a letter to BCBS-NC, specifically offering suggested modifications and asking for an opportunity to meet to collaboratively develop a more patient-friendly policy. That letter, signed by the leaders of nine spine-related professional societies, was very well received by BCBS-NC, so much so that at the start of the meeting, they provided meeting participants with a revised copy of their lumbar fusion policy that incorporated many of the changes that the societies previously requested.

View the New Policy (PDF)

Specifically, BCBS-NC’s new policy added coverage on flatback osteotomy fusions (concern about which was raised in a separate letter from Dr. Errico sent, on behalf of SAS, to BCBS-NC), and they agreed to separate pediatric surgeries completely from these guidelines. However, they did stand firm on not pre-authorizing fusions in cases of iatrogenic instability created at the time of a decompression, stating that one can’t reasonably obtain pre-authorization for something like this, but they did state that they would be understanding on approving the fusion after the fact, if the condition its clearly delineated in the operating report that iatrogenic instability was created necessitating the fusion. Additionally, BCBS-NC was not willing to modify their policy of non-coverage for pure fusions for DDD, but they also didn’t close the door on approvals for that on appeal.

The medical leaders from BCBS-NC also expressed appreciation to the society leaders for the conciliatory tone of the multi-society letter, and complimented the participants on their desire to work constructively to develop policies acceptable to the profession and BCBS-NC. Dr. Errico and other members of the spine community came away from the meeting satisfied that a collaborative, evidence-based approach to such disagreements can lead to positive change. And all of the participants agreed that the nine-society collaborative letter and meeting with this insurer can serve as a model of collaborative advocacy going forward, and should be replicated with other payers promulgating inappropriate or overly restrictive spine surgery-related policies.

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