State No Longer Covers Lumbar Fusion for Common Cause of Back Pain

Monday, July 25, 2016 | 3

Washington state has severely limited coverage by state health care programs of lumbar fusion surgery, a controversial treatment for low back pain on which the Department of Labor and Industries spent $50 million from 2012 to 2014.

Dr. Gary Franklin

The Washington State Health Technology Clinical Committee finalized a determination in January that lumbar fusion for uncomplicated degenerative disc disease would no longer be a covered procedure. The decision applies to state health care programs including Medicaid, state employee benefits and the workers’ compensation program run through the Department of Labor and Industries.

Previously, lumbar fusion, in which adjoining vertebrae in the lower back are joined in an effort to reduce instability and pain, was allowed with preauthorization. Patients with chronic back pain were asked to first go through an intensive, multi-disciplinary pain program to see if that would provide relief.

But evidence presented to the clinical committee persuaded the panel to no longer cover the surgery. Results of lumbar fusion were no better than intensive, non-surgical rehabilitation, according to an analysis of medical evidence presented to the committee. Among the state’s workers’ comp claimants, 22% required another operation within two years of the fusion.

Labor and Industries paid for the surgery for 1,148 claimants from 2012 to 2014, at a total cost of $49.91 million.

And private payers including Aetna and Anthem don’t cover lumbar fusion for low back pain from degenerative disc disease, according to the November presentation to the clinical committee.

“It’s been a long time in coming, but we think this non-coverage is the right thing to do,” Dr. Gary Franklin, medical director of the Washington State Department of Labor and Industries, said on Friday.

Labor and Industries has already amended its payment policies and surgical guidelines effective March 7 to reflect non-coverage of lumbar fusion surgery for uncomplicated degenerative disc disease. Rule-making is under way to modify language regarding the Structured Intensive Multi-Disciplinary Program for Chronic Non-Cancer Pain, or SIMP. Written comments are due by Aug. 26.

The denial of coverage for lumbar fusion surgery does not apply to some back problems, including spondylolisthesis with neurological impairment, Franklin said. Patients with back pain who are no longer covered for lumbar fusion will receive alternative treatment.

“The first thing is to get those patients off the painkillers,” said Franklin, adding that opioids can worsen cases of back pain.

But at least one physician said Washington’s non-coverage determination for lumbar fusion may have gone too far.

Dr. David Ross, a neurologist and chief medical officer of NeuroPAS Global, called Washington’s approach “maybe overreaching.” NeuroPAS Global has developed a method to assess patient pain through bio-feedback and other measures.  

Ross said clinical studies on lumbar fusion have been poorly done, with results “equivocal at best.”

“There’s no good evidence that lumbar fusions help the vast majority of people,” Ross said.

Still, Ross said, there may be a minority of patients for whom lumbar fusion would help. Washington state’s approach means those patients will be deprived of a potentially beneficial treatment. What is not known is how to identify them, he said.

“Because we do not know, it’s become an all-or-none situation,” Ross said.

Washington’s determination of non-coverage for lumbar fusion came through its Health Technology Assessment Program, established by House Bill 2575 in the state’s 2005-06 legislative session.

In a commentary in the New England Journal of Medicine, Franklin and others describe the program as “an unusual initiative in the United States.”

“(HTA is) a government-sponsored program in which formal methods are used to conduct critical appraisals of surgical devices and procedures, medical equipment, and diagnostic tests and to translate the results of those evaluations into coverage recommendations,” the authors wrote.

The program has previously evaluated the effectiveness of spinal injections, spinal cord stimulators and knee replacements. Topics currently under review include pharmacogenetics and negative pressure wound therapy. 

Minnesota is another state that has paid special attention to lumbar fusion in workers’ comp. A section of the Department of Labor and Industry website geared toward employees has a fact sheet on lumbar fusion.

The surgery may be helpful for some with chronic low back pain, the fact sheet says, citing studies that show about half of injured workers get better after the surgery. However, up to one-third of patients report a “poor” result, and 10% to 20% develop a complication.

If a claimant with chronic low back pain chooses not to have the surgery, alternative treatment approaches include intensive physical rehabilitation, chronic pain management, ongoing medication, work conditioning programs and health club memberships, the fact sheet says.