Vertiflex Insurance Issues

[manowar rules]

I adopted Vertiflex to treat LSS a couple years ago, and have hit some home runs with it, although it does have some limitations. Over the past several months however, I have been running into more and more issues with non-Medicare insurance coverage. It used to only be Tricare/VA that denied Vertiflex, but now I'm running into denials from BCBS and United secondary insurance, or even when it's "Medicare-replacement." These plans that covered Vertiflex a year ago are now denying it as "experimental." I have been told that Medicare-replacement plans should approve whatever Medicare approves, but in practice, this does not seem to be the case.

Are others having the same issue? It's hella annoying to have to do a big insurance biopsy before I can decide on a treatment plan for patients.

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[buddababa]

I adopted Vertiflex to treat LSS a couple years ago, and have hit some home runs with it, although it does have some limitations. Over the past several months however, I have been running into more and more issues with non-Medicare insurance coverage. It used to only be Tricare/VA that denied Vertiflex, but now I'm running into denials from BCBS and United secondary insurance, or even when it's "Medicare-replacement." These plans that covered Vertiflex a year ago are now denying it as "experimental." I have been told that Medicare-replacement plans should approve whatever Medicare approves, but in practice, this does not seem to be the case.

Are others having the same issue? It's hella annoying to have to do a big insurance biopsy before I can decide on a treatment plan for patients.

Yes same issue here. Even p2p not helping. Only way to get it approved is to take it to court.

 

[swamprat]

Same here. Rep says they are currently in court with Humana over this as like you said they take Medicare dollars. It’s frustrating to say the least.. even just the fact I have to see if they have Medicare before deciding on a tx plan. Patients ask about it all the time (we have posters on the walls) - sorry sir your 63 no Medicare they don’t cover it here’s some Percocet and go see a surgeon if you want

 

[Status Sciaticus]

whats the cost out of pocket?

 

[buddababa]

whats the cost out of pocket?

Based on your institution negotiated rates, lowest one I’ve seen average 10-14k

 

[drusso]

Yes same issue here. Even p2p not helping. Only way to get it approved is to take it to court.

Cash pay is the way to go.

 

[pmrmd]

Boston Scientific has a legal team on it apparently.

Minute Man might be the way to go for Medicare Replacements since it’s the arthrodesis code.

 

[Status Sciaticus]

Cash pay is the way to go.

couldnt you just have the patient pay cash and let them get reimbursed by the insurance company

 

[bedrock]

Same here. Rep says they are currently in court with Humana over this as like you said they take Medicare dollars. It’s frustrating to say the least.. even just the fact I have to see if they have Medicare before deciding on a tx plan. Patients ask about it all the time (we have posters on the walls) - sorry sir your 63 no Medicare they don’t cover it here’s some Percocet and go see a surgeon if you want

Still, if they are less than Medicare age, they are likely healthy enough for a lami. I wouldn’t want one of these devices unless I was too old or sick for anesthesia/lami.

 

[Status Sciaticus]

Still, if they are less than Medicare age, they are likely healthy enough for a lami. I wouldn’t want one of these devices unless I was too old or sick for anesthesia/lami.

What you are describing is a patients ability to choose whether they want the lami vs. minimally invasive procedure. the problem is that by labeling the latter experimental, they are removing the choice patients have.

 

[gdub25]

I would definitely try Vertiflex first for myself. 1cm incision, 15 minute procedure and out the door. If it does t help we can remove it and do laminectomy.

 

[Taus]

I would definitely try Vertiflex first for myself. 1cm incision, 15 minute procedure and out the door. If it does t help we can remove it and do laminectomy.

Would you change your opinion if able to get a minimally invasive endoscopic lami by an experienced spine surgeon?

around me I see too many healthy 60/70 year olds with severe stenosis getting mild or Vertiflex. I know I see a biased sample of the ones who didn’t do well.... but these are clear surgical candidates who should be getting their problem fixed

 

[TIVAndy]

the outcome is best when mild-mod stenosis - the question is these patients tend to do well with ESI also. severe stenosis pts - prob best served with laminectomy but worth a try with vertiflex

 

[lobelsteve]

the outcome is best when mild-mod stenosis - the question is these patients tend to do well with ESI also. severe stenosis pts - prob best served with laminectomy but worth a try with vertiflex

What percent of MRI L-spine show mild to moderate stenosis?
Are we treating imaging or patients?

 

[Taus]

the outcome is best when mild-mod stenosis - the question is these patients tend to do well with ESI also. severe stenosis pts - prob best served with laminectomy but worth a try with vertiflex

If that’s the case then why do this when esi works for prolonged periods of time. Those mild-mod stenosis patients are not the ones I see getting this done. Also- careful when you call mild/mod stenosis. Often the subarticilar zone shows mod-severe with nerve compression despite mild-mod central. I’d wager the % getting these done bc too old/sick for a lami is low.

 

[TIVAndy]

What percent of MRI L-spine show mild to moderate stenosis?
Are we treating imaging or patients?

you consider vertiflex only when you have neurogenic claudication sx. not stenosis on imaging

If that’s the case then why do this when esi works for prolonged periods of time. Those mild-mod stenosis patients are not the ones I see getting this done. Also- careful when you call mild/mod stenosis. Often the subarticilar zone shows mod-severe with nerve compression despite mild-mod central. I’d wager the % getting these done bc too old/sick for a lami is low.

not saying it doesn't work for severe stenosis but vertiflex in severe stenosis - indirect decompression is not enough "decompression". i try to offer it if patient is not a good candidate or really doesn't want to do a lami. also don't forget a lot of these pts also have anterolisthesis - indication for vertiflex excludes anything above grade 1 but there's also different shades of grade 1 - is it almost grade 2ish/ have instability? - not a great candidate. i've been doing quite a few vertiflexs but now have backed off a bit.

 

[manowar rules]

If that’s the case then why do this when esi works for prolonged periods of time. Those mild-mod stenosis patients are not the ones I see getting this done. Also- careful when you call mild/mod stenosis. Often the subarticilar zone shows mod-severe with nerve compression despite mild-mod central. I’d wager the % getting these done bc too old/sick for a lami is low.

Maybe I’m an outlier but I work in the boonies, I don’t even have a spine surgeon in my county. And past bad/inappropriate spine surgeries in my area have put the fear of god in some of these country patients. Many act like I’ve given them a death sentence when I recommend they see a surgeon. So the amount of selling I have to do on Vertiflex beyond “there is one other thing we can try before lami referral” is nil.

You are right that mild-mod stenosis is usually fine with ESI. My typical patient with Vertiflex has mod-severe stenosis that has failed ESI (usually ESI worked initially, but no longer). Almost all have seen a spine surgeon re: lami/fusion, but either they or the surgeon was unenthused.

All my patients have been 65+, my oldest was 93. Sure severe stenosis is less likely to respond, but I haven’t made a patient worse, and recovery is very simple. So while back-whack for sure has its place, I think the minimally invasive stuff is a great option for elderly patients.

 

[manowar rules]

If that’s the case then why do this when esi works for prolonged periods of time. Those mild-mod stenosis patients are not the ones I see getting this done. Also- careful when you call mild/mod stenosis. Often the subarticilar zone shows mod-severe with nerve compression despite mild-mod central. I’d wager the % getting these done bc too old/sick for a lami is low.

Also, are you the same Taus whose sdn study guide helped my smash the USMLE 10 years ago? Man, you're a legend

 

[Taus]

Also, are you the same Taus whose sdn study guide helped my smash the USMLE 10 years ago? Man, you're a legend

Lol yeah. I had forgotten about that...

definitely a different situation when you don’t have easy access to multiple excellent spine surgeons and those who do endoscopic MIS

 

[TIVAndy]

Lol yeah. I had forgotten about that...

definitely a different situation when you don’t have easy access to multiple excellent spine surgeons and those who do endoscopic MIS

this is crucial. having access to good conservative surgeons with good outcome

 

[Ducttape]

what about MILD for your 65+ patients?

 

[gdub25]

Would you change your opinion if able to get a minimally invasive endoscopic lami by an experienced spine surgeon?

around me I see too many healthy 60/70 year olds with severe stenosis getting mild or Vertiflex. I know I see a biased sample of the ones who didn’t do well.... but these are clear surgical candidates who should be getting their problem fixed

If that were a good option presented by a reputable surgeon for me then yes, I would certainly consider that.

In our practice we have a good understanding of our role in the care of patients. We aren’t surgeons and don’t pretend to be. If we see a patient who we feel Vertiflex could help we discuss with them but also send referral to a surgeon to discuss options. Only after they have been given all options do we make a decision. We find that some patients ta actually aren’t sold on the idea of surgery and would rather live with the pain rather than have an operation. In those patients they almost view Vertiflex as a stepping stone, like an ESI, as one more thing to try before admitting surgery is the only option left. We do 1 to 2 Vertiflex a month total so we aren’t offering it a lot in the first place.

 

[10KHertz]

Shouldn’t be that problematic getting paid... Pull you Medicare LCD on Vertiflex. Makes sure the patient had conservative care, ESI or whatever else they require . Then appeal the denial. If it’s an advantage plan, simple get pre auth prior to scheduling . The experimental denial may be that your documentation is not clear cut.
For example, for MILD you need prior ESI, PT, conservative care 6-8 weeks, HLF >2.5mm, and clear neurogenic clarification symptoms documented ...

 

[drusso]

Shouldn’t be that problematic getting paid... Pull you Medicare LCD on Vertiflex. Makes sure the patient had conservative care, ESI or whatever else they require . Then appeal the denial. If it’s an advantage plan, simple get pre auth prior to scheduling . The experimental denial may be that your documentation is not clear cut.
For example, for MILD you need prior ESI, PT, conservative care 6-8 weeks, HLF >2.5mm, and clear neurogenic clarification symptoms documented ...

How about managed Medicare products?

 

[Agast]

Here's a new one. My patient told me their Humana Medicare plan denied Vertiflex because of the current President...something something politics.

 

[bedrock]

Here's a new one. My patient told me their Humana Medicare plan denied Vertiflex because of the current President...something something politics.

Everything is always the current presidents fault, no matter what it is and who is the current president

 

[10KHertz]

How about managed Medicare products?

We call managed plans Advantage plans .
Some teachers ‘managed’ Medicare plans are becoming terrible in terms of authorizations and benefits ... Cadillac Medicare managed and advantage plans are gone