Up until the middle of the 20th century, coal miners would take a canary into the mines. Canaries are especially sensitive to methane and carbon monoxide, which made them ideal for detecting any dangerous gas build-ups. As long as the canary in a coal mine kept singing, the miners knew their air supply was safe. A dead canary in a coal mine signaled the need for immediate action.
Rising Rates of Denials
We at Orthopedics This Week have been hearing from an increasing number of spine surgeons about rising rates of reimbursement denials for cases that, in the past, would be approved. Furthermore, the denials do NOT seem to have a scientific basis. Could these independent alerts from surgeons be a “canary in the orthopedic mine” in terms of alerting us to a toxic trend on the part of insurance companies?
For example, this professor and chief of spine surgery at a major teaching hospital in the Midwest wrote us and said “We have experienced blanket denials by Medica and others and have just about given up trying (even though this is covered by Medicare, FDA approved and used on-label). I think some of it becomes surgeon fatigue and we stop trying for approval. Perhaps this is the desired goal of the payers.”
His scheduler then followed up with an email to OTW saying “It is my job, when a spinal fusion surgery is scheduled, to make sure these surgeries have prior authorization. In the two years I have been doing this job, I have increasingly had more denials then I have had approvals. In the past I would have sent out 15-20 pages of a patient’s chart, current clinical, X-rays, MRIs, etc. Now we are at 30-60 pages due to the insurance companies wanting proof of non-operative treatments tried. Most insurance companies are requiring physical therapy, for at least eight weeks, epidural steroid injections and physiological evaluations.”
A couple months ago, Dr. Thomas Errico, the president of ISSAS, sent a note to his colleagues alerting them to the Blue Cross Blue Shield of North Carolina’s proposed change in reimbursement policy for spine fusion. A literal storm of response from rank and file spine surgeons prompted nine surgeon societies to form an unprecedented collaboration to respond to the North Carolina proposal. Their letter to BCBS of North Carolina prompted that company to re-examine and change that policy.
But as the stories below illustrate, the North Carolina experience may be the start of a noxious mind set on the part of insurers.
Insurers, Denials and Milliman
Indiana:
“We have been dealing with this for over a year. The increasing rate of denials for coverage has resulted in huge frustration for our patients. We have learned that the only way to get them approved is have the patient call them daily and bug them. The insurance companies constantly lie to the patients telling them that it is our fault for not sending appropriate info, etc. This came to a head for me a few months ago when my scrub tech needed a front/back 5-1 fusion. She went through enormous hassle—constantly being lied to and harassed by the insurance company. But she was persistent-called them every day, sent literature and outcomes data. And the story has a happy ending. They finally OK’d it and she is now returned to work with no pain.”
Arizona:
1.) 65-year-old female (on Ætna) had undergone successful L3-5 laminectomy and fusion for stenosis and degenerative listhesis two years ago, achieving a pain free status for over a year. She presented with severe interval degeneration at L2-3 with back pain and stooped forward posture, decreased ability to walk for distance for one year. She tried physical therapy, medications, but the back pain and stooping slowly increased. CT scan showed L2-3 stenosis, inadequate lumbar lordosis (flatback), degenerative spondylosis at L5-S1 without stenosis. I recommended hardware removal, laminectomy L2-3, TLIF L2-3 and L5-S1, Ponte osteotomies L2-3 and L5-S1 to recover her lordosis, and posterior fusion with instrumentation L2-S1. Ætna denied the surgery, stating Milliman Care Criteria.
2.) 50-year-oldmale (Ætna) underwent left L5-S1 laminotomy and diskectomy for herniation, with complete pain relief for five months. His left leg pain returned though it was most severe along the posterior thigh only, and not down the S1 dermatome. He also developed severe mechanical back pain which was improved by rest. Flexion-extension X-rays did not show instability, but only degenerative disc at L5-S1. New MRI showed typical degenerative L-S1 disc and scar in the operative area but no recurrence of herniation. He tried PT, meds, epidural steroid injections with short-term relief only. I recommended fusion at L5-S1, which Ætna denied. “This case does not meet the Milliman Criteria” was the reason.
3.) 52-year-old male (Humana) with severe back pain for two years, bilateral leg pain and numbness, stooping posture, ambulatory with a quad-cane, could walk less than 1/2 block. X-rays showed 18 degrees of degenerative scoliosis L2-5 with rotational listhesis L2-3, L3-4, and flatback. He was severely out of balance in the sagittal plane (stooping forward). MRI showed severe stenosis at L4-5 with less stenosis L2-3, L3-4. I recommended L2-5 laminectomies, Ponte osteotomies to regain lordosis and correct the curve, TLIF and posterior fusion L2-3. Humana denied the surgery because the “sports medicine orthopod” that reviewed it stated that “TLIF is an experimental procedure”. I pursued an appeal with someone with spine knowledge, and the reviewing neurosurgeon said “there are too many of these fusions being done”. Threatened legal action finally won approval for surgery.
“In my experience, reviewing insurance company physicians hide behind the Milliman Criteria, stating they are not withholding care, but merely outlining what is covered as a benefit based on Milliman. Reviewers insist they are not defining standards of care, only covered benefits. The patient is free to have the surgery for out of pocket payment.”
“The Milliman Criteria seem to be part of the problem. Today I was told by one of the Ætna reviewers that a patient with a Grade 1 isthmic spondylolisthesis with bilateral foraminal stenosis and bilateral progressive L5 EMG proven radiculopathy did not meet criteria for surgery because she did not have a Grade 2 spondy. It took significant work to get the surgery approved.”
Virginia:
“The vast majority of denials that we have seen in Virginia continue to reference the Milliman guidelines as the basis for their denials.”
California:
“Definitely increased denials…all very boilerplate using the same language. ‘Denied based on Milliman Guidelines’.”
Georgia:
“We’ve been struggling with the Milliman nonsense in Georgia. BCBS of Georgia (Well Point- Anthem) was the first in our area. Others have followed suit. I have a patient who is an international jazz singer. Due to L4-5, 5-S1 disc degeneration, she could no longer stand on stage. Her proposed 2-level ALIF was denied based on the Milliman Criteria (BCBS). She waited until her husband could change the insurance carrier for his business so that she could proceed with the proposed treatment. She has had an excellent outcome, and is now back touring Europe. She has indicated her willingness to share her story, as she and her husband were suitably outraged over the whole mess.”
Minnesota:
“The issue that is raised here is in fact the practice of medicine. In deciding that suggested care is or is not appropriate, is a patient and fact set specific practice of medicine. It seems to me that this would fall under the same jurisdiction as legal testimony if it is not standard of care. At a minimum these individuals could be reported to the various professional societies committees on professionalism. I think that the approach of involving the patients and providing them with information on their individual options is exactly where we will need to go.”
Oregon:
“I was copied on an email this morning indicating that Regence BCBS has adopted the Milliman Guidelines, which are perhaps causing surgeons to receive increased denials for fusions for degenerative conditions in Oregon.”
Massachusetts:
“I have just had a denial on a very solid gentleman in his 40’s. He has had increasing pain for over 10 yrs. He has a normal lumbar MRI with the exception of prominent degenerative changes at L4-5. After exhausting conservative measures including injection therapy, he went through a discogram which confirmed L4-5 as his pain generator. After sitting with him and his wife, we decided to pursue an L4-5 fusion. The patient has been saving his vacation time and working in severe pain so that he can use those days for his recovery. MA BC/BS has denied his surgery (and denied his appeal). He will likely go on to lose the job he loves and endure pain with no end in sight. At least the executives at MA BC/BS will get their bonuses.”
Involving Patients
Then one surgeon from California offered the following response tactics when confronted with a denial that is not based on either science or known reimbursement policies.
“Often, when I get a denial authored by a reviewer, I get the patient involved and suggest they do several things. Report the MD to the CA medical society for causing potentially unnecessary pain and suffering by failing to live up to the minimum standards and report the doctor to the insurance commissioner. (The patient also has the right to report the doctor to the respective specialty board.) Then I put in my report that I have suggested these things. Although the medical board never takes action, and a very few patients have actually done the reporting, it is surprising to me how many times I get approval on my appeal!”
What are insurance companies doing? Clearly, there is a rising chorus of spine surgeon alerts. Could it be that the canary is sensing a more noxious environment for patients and surgeons alike?
