MCAC meeting not likely to result in reimbursement changes

Implications: The current data regarding efficacy of spinal fusion does not justify any changes in clinical practice.  

There is insufficient data, new or old, to change reimbursement patterns for spinal surgery.

The publication of the SPORT study (the fusion cohort of patients) in the next two years may help shed some light on the issue of spinal fusion efficacy.

Analysis: Spinal fusion is one of many treatments offered to back pain sufferers, the majority of these treatments do not have level 1 evidence to support their use.  In the 1990's, AHRQ attempted, without success, to find scientific support for standardized treatments for back pain and sciatica.  The highly variable nature of the pathology, and the absence of adequate clinical trials prevent such standardization.

CMS cannot point to any new data indicating a need to reconsider its reimbursement decisions regarding spinal surgery. The rise of spinal surgery rates around the country reflects changed societal attitudes toward treatment expectations, improved surgical technology and safety, modern busy and active lifestyles, and longer life expectancy. In the medicare population, degenerative disc disease occurs in combination with facet arthropathy, spinal stenosis, spondylolisthesis, and ligamentous laxity.  It is naive to attempt to deny coverage for surgery for degenerative disk disease alone.  Isolated degenerative disk disease occurs in young patients only, and even in the young population, it is rarely a surgical condition.

From a public health standpoint, and from a cost-effectiveness standpoint, it might be better to look at the efficacy and necessity of performing lumbar epidural injections and transforaminal injections in the treatment of back pain.  These procedures are performed ubiquitously, much more commonly than spinal fusion, and there is limited data to support their long term benefit.