Spine Surgery Societies’ Statement on Prior Authorization

In June 2022, a coalition of more than a dozen specialty societies, including ISASS, issued a consensus statement on the use of imaging requirements for Prior Authorization.

The letter states:

Position Statement

The doctor-patient relationship is an indispensable component of shared decision-making in choosing to undergo spine surgery. This choice must remain the purview of the patient and the surgeon. Using imaging studies in isolation, without clinical context, may undermine appropriate clinical diagnosis and treatment plans. The concept that image sharing should be a basis for prior authorization is an unnecessary and unwelcome impingement on the doctor-patient relationship, which will detrimentally interfere with the decision for spine surgery. Physicians who treat spine conditions adamantly oppose requiring the submission of patient images as a prior authorization requirement for spine surgery.

Rationale

• The doctor-patient relationship remains the central element in health care and should be shielded from unnecessary intrusion by non-clinicians, including health plans and third-party payers. The image-sharing requirement for prior authorization is another unwarranted intrusion in the doctor-patient relationship and will detrimentally interfere with the decision for spine surgery.
• Neurosurgeons and orthopaedic spine surgeons have undergone extensive training in the natural history, neurological examination and image interpretation of spinal disorders. That foundation provides expertise in the diagnosis, decision-making and formulation of treatment plans — including the decision for surgery.
• The surgeon, not the health plan or payer, has taken the history, examined the patient and reviewed the imaging to determine the appropriate treatment course for a given patient. Imaging must, therefore, be evaluated in the context of the individual patient’s history, physical examination findings, electrophysiologic studies and response to treatments (e.g., physical therapy, injections or other conservative measures) to determine the most appropriate treatment course.

Radiologists play a vital role in health care. However, radiologists have neither seen nor examined the patient, and therefore, the radiology report itself cannot be the arbiter of clinically-meaningful spinal pathology. Furthermore, it is inappropriate for a non-spine surgeon — whether a radiologist, nurse or

• another clinician — who reviews the uploaded images to second guess the decision for surgery solely based on the image, given the lack of clinical expertise and direct involvement with the patient’s care.
• Image sharing software could, in theory, diminish the burden of image submission. However, there are many barriers to implementing this system. Image-sharing software is predicated on ready access to radiographic images, and no spine practice has a single imaging platform or single imaging center. Patients receive imaging from multiple locations, typically with proprietary DICOM^® — Digital Imaging and Communications in Medicine — imaging systems. Communicating with prior authorization image-sharing software platforms using different imaging systems will further complicate an imaging prior authorization requirement.   Therefore, the considerable logistical issues involved with an imaging prior authorization requirement will result in additional practice burdens and delays in care.