Microdiscectomy Insurance Medical Necessity Criteria Are Inconsistent and Unnecessarily Restrictive.

Background: Microdiscectomy for patients with chronic lumbar radiculopathy refractory to conservative therapy has significantly better outcomes than continued nonoperative management. The North American Spine Society (NASS) outlined specific criteria to establish medical necessity for elective lumbar microdiscectomy. We hypothesized that insurance providers have substantial variability among one another and from the NASS guidelines.

Methods: A cross-sectional analysis of US national and local insurance companies was conducted to assess policies on coverage recommendations for lumbar microdiscectomy. Insurers were selected based on their enrollment data and market share of direct written premiums. The top 4 national insurance providers and the top 3 state-specific providers in New Jersey, New York, and Pennsylvania were selected. Insurance coverage guidelines were accessed through a web-based search, provider account, or telephone call to the specific provider. If no policy was provided, it was documented as such. Preapproval criteria were entered as categorical variables and consolidated into 4 main categories: symptom criteria, examination criteria, imaging criteria, and conservative treatment.

Results: The 13 selected insurers composed roughly 31% of the market share in the United States and approximately 82%, 62%, and 76% of the market share for New Jersey, New York, and Pennsylvania, respectively. Insurance descriptions of symptom criteria, imaging criteria, and the definition of conservative treatment had substantial differences as compared with those defined by NASS.

Conclusion: Although a guideline to establish medical necessity was developed by NASS, many insurance companies have created their own guidelines, which have resulted in inconsistent management based on geographic location and selected provider.

Clinical relevance: Providers must be cognizant of the differing preapproval criteria needed for each in-network insurance company in order to provide effective and efficient care for patients with lumbar radiculopathy.

Level of evidence: 5: