MCRA’s Reimbursement and Regulatory departments are pleased to announce the recent publication of part one of a two-part series that critically analyzes the coverage environment for lumbar fusion for degenerative disc disease. In this collaborative publication, Review and Analysis of CMS’ 2006 MEDCAC Panel on Lumbar Fusion for Treatment of DDD, MCRA analysts focus on the Centers for Medicare and Medicaid Services (CMS) 2006 panel meeting on the available evidence for lumbar fusion for DDD as the inflection point for this treatment’s coverage and reimbursement future.

Despite a long-standing evolution in patient care, and widespread use of lumbar fusion techniques for DDD diagnoses, sects in clinical and payor communities have argued that the base of scientific evidence for the continued use of this treatment option for DDD is insufficient. The Medicare program covers lumbar fusion for treatment of DDD at this time, as CMS has not issued any National Coverage Determination (NCD) which would limit coverage for such reasonable and necessary medical services. However, since 2008 a number of commercial health insurance plans have begun to limit or even deny coverage of multi-level lumbar fusion procedures for DDD indications. The origin of many of these non-coverage or ‘coverage-with-limitations’ policies may be linked back to November 30, 2006, when CMS sought recommendations on lumbar fusion for DDD from a panel of experts convened as part of its Medicare Evidence Development & Coverage Advisory Committee (MEDCAC).

In Part One of this White Paper series, MCRA provides an overview of CMS’s NCD process, and details the origin and pivotal role of the MEDCAC. MCRA also critically analyzes evidence presented and reviewed at this 2006 meeting, and introduces some of the main issues identified by committee members in reviewing the body of evidence available for lumbar fusion for DDD.

Electronic copies are available on MCRA’s homepage, while printed copies may be requested by contacting me at ebaldacchino@mcra.com or 202-552-5811. Part Two of this White Paper series, which delves deeper into precise issues identified as problematic to lumbar fusion’s evidence base and compares more recently published clinical literature in order to evaluate lumbar fusion’s continued viability, is expected to be published in late July 2012.