Insurance won't pay for back operation

March 20, 2009 7:23:59 PM PDT
A new option for patients with severe back problems has prompted a debate between some doctors and major insurance companies. The therapy is called disc replacement and while it can help some patients, insurance companies don't always pay.

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Lynn Parish is a patient and no stranger to back and neck pain. In fact, the scars on her neck are like a road map to the multiple surgeries where she's had to fuse damaged vertebrae.

"You'd go to bed and two to three hours later you're waking up in agony," says Parish.

But when another disc in her neck showed signs of similar deterioration, San Francisco orthopedic surgeon Kenneth Light, M.D., offered Parish an alternative. Instead of fusing the damaged vertebrae together, he suggested disc replacement. It's a technology approved by the FDA within the last five years.

"During a spinal operation, what a doctor winds up doing is he separates the vertebrae, removes the disc and creates a new joint or a new surface on top and bottom of vertebrae with these pieces," says Dr. Light.

Dr. Light explains the artificial disc allows the vertebrae to flex from side to side, in a natural motion, that's lost with fusion. And Dr. Light says the differences between the two procedures can be dramatic.

"You have to understand I've had four standard fusions in the neck. When I woke up from this surgery, it was nothing like the other surgeries," says Parish.

Parish says she recovered with none of the lingering pain she experienced before. But the price was steep, since her insurance wouldn't cover the cost of the procedure.

"The surgery was $47,500 out of pocket. We tapped into our retirement for that," said Parish.

Although disc replacements have been used in Europe for more than 20 years and have FDA approval in this country, a number of insurance companies still consider them experimental and other plans approve them only in very limited cases.

"In order for you to get good result from a disc replacement, only the disc can be injured," says Paul Slosar, M.D.

Dr. Slosar is an orthopedic surgeon with St. Francis Hospital in San Francisco. While he says disc replacement is a solid technology, he believes fusion techniques have progressed as well and are highly effective for the majority of cases where there is damage beyond the disc itself.

"Still at the end of the day it gets down to taking care of the right kind of patient. Many patients who are candidates for back surgery, when you get down to looking at the X-rays and MRI's, you find they're not candidates for disc replacement," says Dr. Slosar.

Anthem Blue Cross is one of several insurance companies that considers the procedure "investigational and not medically necessary." In a statement they also ad that: "While the FDA has approved the procedure... Authorizing broader use requires a five-year review. Blue Cross looks forward to such medical research being completed in the next few years."

But Dr. Light believes there are more than enough patients like Parish who would benefit from the increased mobility, and faster recovery times, to justify the coverage.

"She had the operation, she was in the hospital for only one day, went home the next day and was cured. And why Blue Cross, Blue Shield, the insurance industry won't embrace this technology is really a difficult thing for me to understand," says Dr. Light.

Dr. Light believes the policy is coming between patients making decisions based on their doctor's recommendations. When it comes to cost, Dr. Light points out disc replacement runs about half as much as spinal fusion.

"It is in my opinion the single greatest advancement in spinal surgery in the last 50 years," says Dr. Light.

There are several competing models of disc replacements now on the market. There are also new micro-bracing technologies emerging as well.

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