The Payor Policy Review Committee (PPRC) and the Coverage Committee within NASS’ Health Policy Council continue to advocate for fair and appropriate coverage decisions through evidence-based medicine. An area of particular interest for NASS has been coverage policies determined by the Centers for Medicare and Medicaid (CMS) and Medicare Administrative Contractors (MACs) due to the number of lives they cover. We are excited to share some of our recent successes with you so you are able to continue to guide and provide appropriate spine care to your patients.
Back in February 2020, NASS members became aware of an unfavorable coverage policy for vertebral augmentation from Noridian, which is a MAC serving California, Hawaii, Nevada, Guam, American Soma and Northern Mariana Islands. This local coverage determination only covered treatment for patients with fractures less than 6 weeks old, which could negatively impact patient outcomes and a provider’s ability to provide evidence-based care. In addition, this coverage determination required consensus from a multidisciplinary team of four physicians. This could lead to increased costs and delay in treatment. NASS acknowledges there are providers from several specialties that are able to diagnose and treat acute compression fractures. The requirement for multiple provider visits represented unnecessary costs and burden on the patients. As a result, NASS worked with the Multisociety Pain Workgroup (MPW) to draft a comment letter advocating for a revision of this coverage determination that better reflected the literature.
In addition to providing a detailed comment letter addressing our concerns, NASS leadership met with a Medical Director from Noridian to further discuss the coverage issues with its Vertebral Augmentation local coverage determination and share our rationale. The meeting was very productive as Noridian leadership acknowledged and appreciated NASS’ evidence-based and ethical approach in addressing these coverage issues while making sure that our processes are transparent and NASS reviewers’ disclosures are taken into the consideration in order to avoid any bias. After much discussion and advocacy from NASS, MPW and other stakeholders, Noridian changed the local coverage determination to allow treatment for acute and subacute (6-12 weeks) fractures and removed the multi-disciplinary team consensus requirement. Please click here
to access Noridian’s recently revised (as of January 10, 2021) coverage determination on Vertebral Augmentation.
NASS’ commitment and dedication in pursuing evidence-based coverage policies have also resulted in additional opportunities with MACs in the recent months. In October 2020, NASS was invited by the MAC Novitas to nominate a representative to serve as a subject matter expert at the Contractor Advisory Committee (CAC) meeting on epidural interventions that was held on February 11, 2021. These ongoing collaborations between NASS and CMS/MACs are extremely important as it gives us an opportunity to provide evidence-based recommendations before local coverage determinations are developed, helping to prevent adverse coverage determinations from taking effect.
We would like to extend our sincere appreciation to NASS’ Health Policy Council leadership including Mitchell Reiter, MD; Scott Kreiner, MD; Christopher Kauffman, MD; Zoher Ghogawala, MD, FACS; Scott Cowan, MD; John Easa, MD; and William Mitchell, MD for their efforts in advocating for fair reimbursement decisions. These efforts continue to benefit spine care providers and the millions of patients you serve.
Please click the link to access NASS’ evidence-based Coverage Recommendations
and contact NASS staff at [email protected]
with any questions.