Prior authorization is an administrative process requiring physicians to obtain pre-approval for medical treatments or tests before rendering this care to their patients. Obtaining this approval from payers is burdensome and costly to physician practices. It requires providers and their staff to spend considerable time communicating with payers, thus taking away from time spent in actual patient care. This administrative process is often required even for treatments and tests that are eventually routinely approved.1,2,3,4 As a result, needed care may be denied or delayed.
Commercial health plans and other third-party payers are now considering incorporating real-time image sharing as a prior authorization requirement for spinal surgery. The decision for surgical intervention for spinal disorders requires a comprehensive patient history, physical examination and review of imaging studies. All three are necessary components of the decision-making process. Imaging on its own should never be the basis for instituting treatment. A tenet of surgical treatment is never to treat the radiograph but always treat the patient and their symptoms.
Despite this, payers are proposing to use imaging as the sole or predominant factor in determining prior authorization for spine surgery. This is problematic for three reasons:
- The requirement for image-sharing software to enable this transaction represents an additional cost and administrative burden for physician practices;
- Interpretation of imaging by physicians who are not actually examining the patient may lead to erroneous conclusions; and
- Reliance on imaging unduly devalues the importance of patient history and examination in the decision process for treatment.
The doctor-patient relationship is an indispensable component of shared decision-making in choosing to undergo spine surgery. This choice must remain the purview of the patient and the surgeon. Using imaging studies in isolation, without clinical context, may undermine appropriate clinical diagnosis and treatment plans. The concept that image sharing should be a basis for prior authorization is an unnecessary and unwelcome impingement on the doctor-patient relationship, which will detrimentally interfere with the decision for spine surgery. Physicians who treat spine conditions adamantly oppose requiring the submission of patient images as a prior authorization requirement for spine surgery.
- The doctor-patient relationship remains the central element in health care and should be shielded from unnecessary intrusion by non-clinicians, including health plans and third-party payers. The image-sharing requirement for prior authorization is another unwarranted intrusion in the doctor-patient relationship and will detrimentally interfere with the decision for spine surgery.
- Neurosurgeons and orthopaedic spine surgeons have undergone extensive training in the natural history, neurological examination and image interpretation of spinal disorders. That foundation provides expertise in the diagnosis, decision-making and formulation of treatment plans — including the decision for surgery.
- The surgeon, not the health plan or payer, has taken the history, examined the patient and reviewed the imaging to determine the appropriate treatment course for a given patient. Imaging must, therefore, be evaluated in the context of the individual patient’s history, physical examination findings, electrophysiologic studies and response to treatments (e.g., physical therapy, injections or other conservative measures) to determine the most appropriate treatment course.
- Radiologists play a vital role in health care. However, radiologists have neither seen nor examined the patient, and, therefore, the radiology report itself cannot be the arbiter of clinically-meaningful spinal pathology. Furthermore, it is inappropriate for a non-spine surgeon — whether a radiologist, nurse or another clinician — who reviews the uploaded images to second guess the decision for surgery solely based on the image, given the lack of clinical expertise and direct involvement with the patient’s care.
- Image sharing software could, in theory, diminish the burden of image submission. However, there are many barriers to implementing this system. Image-sharing software is predicated on ready access to radiographic images, and no spine practice has a single imaging platform or single imaging center. Patients receive imaging from multiple locations, typically with proprietary DICOM® — Digital Imaging and Communications in Medicine — imaging systems. Communicating with prior authorization image-sharing software platforms using different imaging systems will further complicate an imaging prior authorization requirement. Therefore, the considerable logistical issues involved with an imaging prior authorization requirement will result in additional practice burdens and delays in care.
Endorsed by the:
- American Academy of Orthopaedic Surgeons/American Association of Orthopaedic Surgeons
- American Association of Neurological Surgeons
- Cervical Spine Research Society
- Congress of Neurological Surgeons
- AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves
- International Society for the Advancement of Spine Surgery
- Lumbar Spine Research Society
- North American Spine Society
- Scoliosis Research Society
1 Prior Authorization and Utilization Management Reform Principles. https://www.ama-assn.org/system/files/2019-06/principles-with-signatory-page-for-slsc.pdf. 2 2021 AMA Prior Authorization (PA) Physician Survey. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf 3 2019 Regulatory Relief Coalition Prior Authorization Survey Results. https://www.regrelief.org/wp-content/uploads/2019/12/RRC-Prior-Authorization-Survey-Results-FINAL-7-26.pdf 4 2019 AANS/CNS Prior Authorization Survey Results. https://www.aans.org/-/media/Files/AANS/letters/Neurosurgery-Prior-Authorization-Survey-Results.ashx