Navigating Health Insurance Coverage for Minimally Invasive SI Joint Surgery

In light of new findings from a 6-year follow-up study showing that patients who underwent minimally invasive sacroiliac (SI) joint fusion had significant improvements in pain and disability as well as decreased likelihood of continued opioid use compared with patients whose health insurance denied coverage for the procedure, 1 SpineUniverse talked to Jeffrey Dunn, President and Chief Executive Officer of SI-BONE about what surgeons can do to help secure coverage for appropriate patients.
Medicine bottle top with a push twist openingThis independent study showed rapid and dramatic pain relief for people who were able to have a payor cover the surgery. Photo

What were the overall clinical implications of the study by Vanaclocha et al?

Mr. Dunn: This independent study showed rapid and dramatic pain relief for people who were able to have a payor cover the surgery. Patients who were denied coverage for the surgery and were relegated to conservative care generally experienced worsening pain, functional status and work status.

Importantly, patients who underwent minimally invasive SI joint fusion with the iFuse Implant™ were 11 times less likely to be opioid users at their last visit, compared with patients who received conservative management. Patients in this study had mean pain scores of approximately 8 on a 0 to 10-point scale at baseline, suggesting that even patients who are experiencing a great deal of pain can find relief from surgery, and that relief corresponds with a reduced likelihood of continuing to take opioids.

In addition, the study confirmed the safety of this procedure and low revision rates found in previous trials.

Do you think the Vanaclocha study and other recent studies will impact health insurance coverage of minimally invasive SI joint fusion?

Mr. Dunn: I am cautiously optimistic that with all of this evidence—including the latest evidence from the Vanaclocha study,1 a pooled analysis of three prospective trials,2 and the National Institute for Health and Care Excellence (NICE) guidance supporting use of minimally invasive SI joint fusion for chronic sacroiliac pain3—we will start to see more health insurance companies cover the procedure.

How can health care providers help patients who are denied coverage for minimally invasive SI joint fusion?

Mr. Dunn: I know that it is very frustrating and time consuming for physicians and their offices to make the case for their patients with their insurers. However, we are now starting to see level 1 appeals being approved by nurse-reviewers at one of the top payors, and others have adopted positive coverage policies or consistently approve the procedure on a case-by-case base, so even some of the biggest payors are responding positively to support patients. Surgeons who want to appeal coverage denials should document that they have followed guidelines on conservative care and diagnostic algorithms for SI joint pain from the North American Spine Society or International Society for the Advancement of Spine Surgery.

More positive payor coverage policies such as TRICARE and Health Care Service Corporation (HCSC) have been published.  The level 1 appeal decisions are also a good sign that things are moving in the right direction and I believe a predictor of future coverage policies. Given, we believe, that every society that we talk to is advocating for coverage, we hope that we will get to positive written policies so coverage is routine and surgeons can help more patients soon and in the coming years.

Updated on: 09/19/19
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Predictors of Success With the iFuse Implant System Confirmed in Pooled Analysis

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