Recently, a few of our readers expressed interest and concern regarding reimbursement issues from major insurance companies (Aetna, Cigna and United Health) on the XLIF. Mike Matson originally reported this on November 20th. These companies have declared the XLIF unproven, and have stopped covering it. It perplexes TSB and hopefully many of our readers, why at this juncture has this become an issue with these payors? Since these insurers cover 66 million people, could it be that they are looking at this as a strategy to minimize payment on this product/procedure? Matson goes on to say that XLIF is billing as an ALIF because it is an anterior approach. But the real question is whether the insurance industry will be able to differentiate between a true ALIF and an XLIF based on hospital claims?
Will this news create an overhang on NUVA shares, or is this a strategy by the analysts to lower 2010 guidance. I have to side with NuVasive, unfortunately, there is one looming story that comes out of this report, it may be time for NuVasive to post results that insurance issues are not going to be an obstacle to beat its estimates.
Alex it's time to perform your magic! TSB wants to know what our readers think?
The insurance companies reason for not covering XLIF is a lack of prospective long term data. This makes me chuckle since lumbar TDR has just that, and is still not covered for being "experimental".
ReplyDeletePerhaps we should take a trip down memory lane and look at the experience of two of the most successful procedures in Orthopedics, Hip and Knee replacements. Did prospective, long term data prove to the insurance companies that these procedures were efficacious? Oh wait, thats right, there were no prospective, long term studies to prove that these procedures work, and yet they are now the gold standard.
If insurers don't want to pay for procedures that lack long term prospective date, fine, but at least pick one side of the fence and stay on it.
Insurers run their organizations like a business, and this is an instance of seizing and opportunity to increase profits. The question is not whether XLIF, spinal arthroplasty or any other poorly reimbursed procedures are effective. The real question is whether or not patients are willing to pay out-of-pocket for a procedure that, in their and/or their surgeon's opinion, provides a significantly better outcome. Sometimes the answer is yes, and when the patient can afford to pay, the insurer ends up not covering the procedure. The insurer ends up saving a substantial amount of money in the end.
ReplyDeleteOn the flip-side, when the insurer has a stake in the outcome of the procedure, (i.e., worker's comp) they are often times more willing to cover an “unproven” procedure, especially when the patient returns to normal function sooner. Relative to insurers, the FDA is considered more so a non-biased organization that exists solely to ensure the safety and effectiveness of products. For this reason, if the FDA approves the product by stating it is “safe and effective” then one would argue that this should be enough to provide insurance coverage for the procedure.
This is a case of the "hogs getting slaughtered." They have been charging astronomical prices for XLIF implants and monitoring disposables. I have seen prices of $8000+ for the otherwise unremarkable XLIF PEEK cage. This is at least twice what the going rate is for a comparable ALIF.
ReplyDeleteSo the question becomes: Is the XLIF superior enough to a standard ALIF (or TLIF for that matter) to justify its increased implant costs and the costs of monitoring. That's a question which is debatable, and I'm not sure NuVasive has made that case to the payors.
Just to clarify Mr. Snyder's post: The FDA has not approved the XLIF procedure as "Safe and Effective." It was cleared as "substantially equivalent" to another PEEK ALIF device. With this designation, how can one justify 2X price over the predicates?
ReplyDeleteIf companies want to charge premium pricing, the burden is on them to invest in studies that provide clear and convincing data the benefits outweigh the additional cost.
Strange isn't it that the insurance companies do not want to reimburse the procedure when this country is heading towards socialized medicine!!! One less thing for them to pay, a way to cut costs!!!What 's next? One of the best thing about USA is Innovation and Development of new ideas and technologies. This we do best and should continue to promote whole heartily... Unfortunately, at the rate we are going, it will be one more thing that the chinese will soon have over us.
ReplyDeleteI want to clarify something. There is no XLIF Peek cage that costs $8000.
ReplyDeletehow much is XLIF then compared to ALIF?
ReplyDeleteThe key difference is in the cost of the NuVasive-required disposables for the nerve monitoring system. Can be upwards of $5000 per procedure. This can easily bring the price of a one level procedure over $8000. ALIF pricing has been coming down a bit - I've seen 2K and no monitoring required.
ReplyDeleteFirst of all you need to get your facts straight before you start quoting prices SpineDoc1.
ReplyDeleteXLIF implants are not 8k and Their monitoring is far less expensive than traditional Neuro-Monitoring that is currently being provided by out side groups. XLIF saves hospitals thousands of dollars with this procedure and patients do great. sounds to me like your an access surgeon with an Axe to gring!
For those trying to confuse the conversation on the cost for a one level XLIF with all the trimmings (electrode & retractor disposables, XLIF cage, plate/bolts, formagraft), lets talk turkey. At list, that construct will set a hospital back over $25,000 (do you want exact numbers?). Please don't continue to confuse us with your sales jargon. We can continue by listing the prices by line item if you want, but lets wait. Let's continue forward now on this dialogue and not stray off line. Your rebuttal?
ReplyDeleteSounds to me like the Nuvasive rep needs to run a spell/grammar check!
ReplyDeleteHas anyone considered that the insurance companies don't want to pay for the XLIF procedure because they are seeing additional costs associated with the complications from the procedure which they are not seeing with ALIF patients? Whether the complications are transient or not it is still a complication! How many of us have quit doing the procedure because of the new pain it has created in our patients and we hope it is going to only be transient. Additionally, if you are relying on the NuVasive EMG monitoring alone that is suicide.
ReplyDeleteThis comment has been removed by a blog administrator.
ReplyDeletewhat would be the consequnce of insurance companies not providing reimbursement to neuro monitoring?
ReplyDeletethanks,
I was denied coverage, for the XLIF procedure, last week.
ReplyDeletescam company! getting caught telling surgeons to place the codes as an ALIF, which is not correct this should be considered an illegal way of getting approvals, plus there are tons of issues with this procedure, plating , subsidenc of the implant, and yes the implant costs generally around 6,500 and the plate costs about 5,000 not counting the disposables,,,,,,.....
ReplyDeleteOne question I have: Is coding for an ALIF when you've performed an XLIF in an effort to receive payment considered fraudulent.
ReplyDeleteI have had successful surgery with NuVasive's XLIF procedure. The down time was less. My mobility is restored and my pain is minimal. The Insurance Cartel refusing to pay for this procedure is just another episode in the chapter of them denying medical care to drive up their greedy profits. Who do you trust...Doctor's expert opinions or clerks who deny claims on the phone?
ReplyDeleteHow about the surgeons performing the XLIF on patients so THEY can recoup the professional charge for monitoring. This is illegal for the surgeon to do, however, Nuvasive is telling the surgeons that this is ok. They are making 1k+ on top of their surgeons fees. This gives them incentive to use the system and since it is in their "professional medical opinion", whose gonna argue? The Nuvasive model is slick and has wow factor. If you talk to anyone within the neurophysiology community (PhDs, MDs) they will tell you that it is inaccurate and too expensive. Besides, the 'reps' are not qualified to interpret or troubleshoot the equipment. They are not even certified. This is another example of bad medicine that unethical surgeons are using to line their own pockets.
ReplyDeleteHow about DLIF, Oracle Spacer and now Dupry's Cougar? Are they as good as or even better than Nuvasive's XLIF? What are the pros and cons? Thank you.
ReplyDeleteWell as someone who had THE XLIF PROCEDURE i WISH THERE WAS MORE INFORMATION ABOUT THE PROCEDURE IN 2007 OTHER THAN THAT IT IS SUCCESSFUL FOR ME THE PATIENT ITS BEEN HELL. HORRIBLE PAIN AND PERMANENT FEMORAL NERVE SEVERED. NOW UNABLE TO WALK WITHOUT A WALKER OR FOR LONG DISTANCES IN A WHEELCHAIR. I WAS A FULL TIME WORKING RN NOW I'M ON DISABILITY ON SERIOUS MEDICATIONS. FOR ME THIS WAS A LIFE CHANGING EVENT
ReplyDeleteAnonymous, I To had what was supposed to be PLIF in 2010 and woke up from the surgery in excruciating pain in my hip, leg, groin and testicle.The Doctor said its normal and will get better and chalked me up as a success. Only gave me vicodin for the pain. After seeing another neurologist I had an EMG and found that I have a severed femoral nerve. The pain is un-managable and can only walk short distances with a cane. My leg is mostly paralyzed.I am on strong pain medication which does little to help. Before This I was a full time worker and enjoyed many activities. Now 2.5 years later I am on social security and quickly losing everything I have worked my hole life for.The damage done to me by this xlif proscedure is far worse than the damage from the car accident I had in 03. I almost got stuck with a 100k doctor bill on top of the insurance company denied payment because what the insurance company ad I approved was a PLIF.
DeleteIt all depends on which organization is managing your coverage. Insurance companies should pay for any procedure approved by FDA. I've had three XLIF and one ALIF already and all have been paid by my insurance company; no questions asked.
ReplyDelete