Vol. 95, September 2023 DC E-Newsletter
House Committee Advances Prior Authorization Legislation
On July 26, the House Ways and Means Committee advanced legislation — the Health Care Transparency Act (H.R.4822) — to reform prior authorization in the Medicare Advantage (MA) program. The broader bill included the neurosurgery-backed Improving Seniors’ Timely Access to Care Act (H.R. 3173 in the 117th Congress). Before consideration, the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) joined the Regulatory Relief Coalition in sending a letter to committee leaders. If adopted, the bill would establish an electronic prior authorization program that requires MA plans to provide real-time approval of routinely approved services.
In applauding the committee for taking this action, CNS/AANS Washington Committee chair Russell R. Lonser, MD, FAANS, stated:
The rampant overuse of prior authorization continues to cause inappropriate delays and denials of medical treatments that our seniors need, and we appreciate the ongoing efforts of the Ways and Means Committee to advance reforms that enjoy broad bipartisan support in the House and Senate. Patients can ill afford to wait any longer for policymakers to hold Medicare Advantage plans accountable, and America’s neurosurgeons urge Congress to get this legislation across the finish line this year.”
GOLD CARD Act Introduced in the House of Representatives
On July 27, Reps. Michael Burgess, MD, (R-Texas) and Vicente Gonzalez (D-Texas) introduced the Getting Over Lengthy Delays in Care As Required by Doctors (GOLD CARD) Act (H.R. 4968). This bipartisan bill would exempt providers from prior authorization requirements in the Medicare Advantage program for one year if at least 90% of prior authorization requests in the preceding year are approved. The CNS and the AANS endorsed the legislation.
CNS/AANS Washington Committee chair Russell R. Lonser, MD, FAANS, was featured in Rep. Burgess’ press release:
Our patients cannot afford to wait or jump through unnecessary hoops to get care for painful, debilitating and life-threatening neurologic conditions. The GOLD CARD Act is a commonsense approach to addressing the unnecessary burdens and delays caused by the widespread use of prior authorization, and America’s neurosurgeons thank Reps. Burgess and Gonzalez for introducing legislation to expedite this process so our nation’s seniors get timely access to care.
In reporting on the GOLD CARD Act, Medical Economics published an article that included Dr. Lonser’s comments.
House and Senate Appropriators Advance Health Spending Bills
On July 14, the House Labor, Health and Human Services, Education and Related Agencies (Labor, HHS and Education) Appropriations Subcommittee approved its Fiscal Year 2024 legislation. Subsequently, on July 27, the Senate Labor, HHS and Education Appropriations Subcommittee advanced its version of the legislation. The bills support programs of interest to neurosurgery, including funding for:
- National Institutes of Health;
- Traumatic brain injury;
- Firearm injury and mortality prevention
- Military and civilian partnership for trauma readiness;
- Children’s hospitals graduate medical education; and
- Pediatric subspecialty loan repayment.
Click here for the House bill and here for a summary of the legislation. The Senate bill is available here. Click here for the Senate committee report and here for an overview of the bill.
Pediatric Diseases Research Legislation Approved by House Committee
On July 19, the House Committee on Energy and Commerce approved the Gabriella Miller Kids First Research Act 2.0 (H.R. 3391). Introduced by Rep. Jennifer Wexton (D-Va.), this legislation would fund research on pediatric diseases and disorders at the National Institutes of Health, including pediatric and childhood cancer. The CNS and the AANS have endorsed the House and Senate bills.
Neurosurgery Urges Congress to Repeal Ban on Physician-Led Hospitals
On July 27, the CNS and the AANS joined a coalition supporting the Patient Access to Higher Quality Health Care Act (S. 470/H.R. 977). Introduced in the Senate by Sen. James Lankford (R-Okla.) and in the House by Reps. Michael C. Burgess, MD, (R-Texas) and Henry Cuellar (D-Texas), the legislation would repeal the Affordable Care Act’s ban on physician-owned hospitals, enhancing patient choice and improving competition in the health care marketplace.
Click here for the letter endorsing the bill.
House and Senate Committees Pass Public Health Preparedness Legislation
On July 17, the House Committee on Energy and Commerce passed the Preparing for All Hazards and Pathogens Reauthorization Act (H.R. 4421). Subsequently, on July 20, the Senate Committee on Health, Education, Labor and Pensions passed its version of the bill, the Pandemic and All-Hazards Preparedness Act (S. 2333). Both bills would reauthorize the public health preparedness program through Fiscal Year 2028. Supported by the CNS and the AANS, the legislation would reauthorize the Military and Civilian Partnership for the Trauma Readiness grant program — also known as MISSION ZERO — which provides funding for civilian trauma centers to train and incorporate military trauma care providers and teams into care centers. The Senate and House must now negotiate the differences in both bills before the current program expires on Sept. 30.
Coding and Reimbursement
CNS and AANS Advocacy Results in CMS Rescinding Edit for Decompression Add-on Codes
Due to CNS and AANS leadership and advocacy, the Centers for Medicare & Medicaid Services (CMS) rescinded an incorrect National Correct Coding Initiative (NCCI) edit restricting the reporting of spinal fusion codes (Current Procedural Terminology (CPT®) codes 22630, 22632, 22633 and 22634) with decompression add-on codes (CPT codes 63052 and 63053). Unsatisfied with the agency’s original plan, the CNS and the AANS led a coalition letter effort urging a swift resolution. Following an Aug. 24 meeting, which was joined by representatives from the American Academy of Orthopaedic Surgeons and North American Spine Society, CMS stated it would resolve the error by Oct. 1.
Until the error is corrected, CMS recommends that neurosurgeons submit claims for these services using modifier -59, Distinct Procedural Service. Alternatively, practices may hold claims for these codes until CMS corrects the error.
Neurosurgery Presses Aetna to Modify ACDF Surgery Policy
Despite two decades of scientific literature, Aetna remains the only major commercial insurer that routinely denies coverage for interbody spacers in anterior cervical discectomy and fusion (ACDF). Aetna’s policy deems poly-ether-ether-ketone, or PEEK, and metallic spacers (CPT code 22853) as “experimental and not medically necessary” for routine ACDF. On Aug. 30, the CNS, AANS and CNS/AANS Joint Section on Disorders of the Spine and Peripheral Nerves sent a letter to Aetna urging the health plan to update its coverage to empower the surgeon and the patient to decide which implants to use in their spine surgery.
Aetna clinical policy staff has agreed to meet with representatives from neurosurgery to discuss this issue.
CNS and AANS Express Concern about Cigna’s Intraoperative Neuromonitoring Coverage Policy
On June 14, representatives from the CNS and the AANS led a meeting with Cigna medical directors and representatives from the American Academy of Neurology, American Academy of Orthopaedic Surgeons, International Society for the Advancement of Spine Surgery and North American Spine Society to express concerns about Cigna’s intraoperative neuromonitoring (IONM) policy. Previously, the CNS and the AANS raised these concerns in a March 29 letter to Cigna.
Following the meeting, Cigna sent a letter to the CNS and the AANS acknowledging neurosurgery’s recommendations to cover IONM during cervical spine surgery in patients with ossification of the posterior longitudinal ligament (OPLL) or cervical spondylotic myelopathy (CSM). Cigna indicated it will update its IONM Coverage Policy to clearly state that the health plan will cover IONM during cervical surgery in patients diagnosed with OPLL. In addition, Cigna noted that the policy accounts for high-risk patients undergoing spinal surgery in the presence of significant spinal cord compression and myelopathy as part of the claim review for IONM, including those with CSM.
Neurosurgery Supports Medicare Coverage of Carotid Artery Stenting
On Aug. 4, the CNS, the AANS and the CNS/AANS Joint Cerebrovascular Section sent a letter to CMS thanking the agency for releasing a Decision Memo on Carotid Artery Stenting (CAS) and encouraging CMS to expand the indications for CAS. Earlier this year, the neurosurgical groups wrote CMS urging the agency to revisit the indications for CAS.
CNS and AANS Support Proposed Breakthrough Device Coverage Policy
On Aug. 28, the CNS and the AANS submitted comments to the Centers for Medicare & Medicaid Services responding to a proposal to cover devices cleared under the Food and Drug Administration’s (FDA) Breakthrough Device pathway. The neurosurgery groups expressed support for the new CMS coverage pathway, Transitional Coverage for Emerging Technologies, urging the agency to implement the program in a way that will safeguard high-quality and real-world evidence development for the technologies selected.
Cigna and UnitedHealthcare Reduce Use of Prior Authorization
Following sustained advocacy efforts by neurosurgery and others, UnitedHealthcare recently announced that beginning on Sept. 1, it would start a two-phased approach to eliminate prior authorization for 20% of covered services, including disc arthroplasty (CPT codes 22864 and 22865). The company also said it plans to roll out a “gold card” program next year, eliminating most prior authorization requirements for physicians with high approval rates.
On Aug. 24, Cigna followed suit and announced it would also take steps to reduce the number of procedures subject to prior authorization. Neurosurgical codes no longer requiring prior authorization include CPT code 37217, Transcatheter intravascular stent placement intrathoracic carotid or innominate artery via open ipsilateral cervical carotid artery exposure, and CPT code 61885, Insertion/replacement cranial neurostimulator pulse generator.
Government Watchdog Raises Concerns about Prior Authorization in Medicaid
In July, the U.S. Department of Health and Human Services Office of Inspector General (OIG) issued a report raising concerns about prior authorization in Medicaid managed care. In the report titled “High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care,” the OIG noted that some people enrolled in Medicaid managed care may not be receiving all medically necessary health care services intended to be covered, citing the high number and rates of denied prior authorization requests. The OIG found limited oversight of prior authorization denials in most states, including limited access to external medical reviews.
To address these shortcomings, the OIG recommended that the Centers for Medicare & Medicaid Services take the following steps:
- Require states to review the appropriateness of a sample of prior authorization denials regularly;
- Require states to collect data on prior authorization decisions;
- Issue guidance to states on the use of prior authorization data for oversight;
- Require states to implement automatic external medical reviews of upheld prior authorization denials; and
- Work with states to identify and address Medicaid managed care plans that may be issuing inappropriate prior authorization denials.
OIG Releases New Plan for Oversight of Managed Care
In August, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a new work plan announcing oversight of Medicare and Medicaid managed care. The OIG noted that a primary goal is to “promote access to care for people enrolled in managed care,” particularly since access to services is the foundational principle for care, including the timeliness of care. The OIG noted that harmful delays in care could result from lengthy prior authorization processes, citing previous reports finding that Medicare Advantage and Medicaid Managed Care plans used prior authorization to inappropriately deny medical care.
Neurosurgery Comments on Proposed 2024 Medicare Physician Fee Schedule
On Sept. 6, the CNS and the AANS submitted comments on the Calendar Year (CY) 2024 Medicare Physician Fee Schedule Proposed Rule. The neurosurgical groups expressed concerns about the 3.5% decrease in the CY 2024 conversion factor, primarily stemming from a new office visit add-on code (G2211) for complex services. In their letter, the CNS and the AANS urged the Centers for Medicare & Medicaid Services (CMS) to:
- Halt implementation of the G2211 add-on code;
- Adjust the 10- and 90-day global codes to reflect increases in the value of post-operative evaluation and management services; and
- Accept the American Medical Association/Specialty Society Relative Value Scale Update Committee-recommended values for the total disc arthroplasty code (CPT code 22860).
The CNS and the AANS also commented on Medicare’s Quality Payment Program issues. Among other things, the letter:
- Objected to the new Merit-Based Incentive Payment System Value Pathways framework;
- Requested that CMS maintain measure #128: Body Mass Index Screening so that it is available to specialists who otherwise have access to very few relevant measures; and
- Registered concerns about the flawed approach to cost measurement and the inclusion of surgeons in the newly developed Low Back Pain episode-based cost measure, which is aimed at evaluating non-operative, chronic care.
Responding to neurosurgery’s ongoing advocacy, CMS proposed suspending the implementation of the Appropriate Use Criteria for Advanced Diagnostic Imaging Program due to unsurmountable operational challenges and a reassessment of the program’s utility.
Besides their letter, the CNS and the AANS joined several coalition letters. Click here for a surgical coalition letter opposing the G2211 add-on code, here for the Alliance of Specialty Medicine letter and here for the Physician Clinical Registry Coalition letter.
For additional details about the proposed rule, click here for a summary of provisions of interest to neurosurgery and here for a CMS fact sheet.
Drugs and Devices
Neurosurgery Partners with FDA for Breakthrough Device Innovation
Through its Drugs and Devices Committee, the CNS and the AANS are collaborating with the Food and Drug Administration (FDA) in its Total Product Life Cycle Program (TAP). The TAP pilot program is designed to provide participants with earlier and more frequent interactions with the FDA and more strategic engagement with non-FDA stakeholders to help spur rapid development and timely and widespread patient access to safe, effective, high-quality medical devices. This program will assist manufacturers of neurological devices in gaining approval — from concept to market — through the FDA’s Breakthrough Devices Pathway.
Thus far, the CNS/AANS Drugs and Devices Committee leaders have met with FDA TAP staff several times, including during the CNS Annual Meeting in Washington, DC.
2022 MIPS Final Scores and Payment Adjustments Now Available
The Centers for Medicare & Medicaid Services (CMS) recently released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2022 performance year, including MIPS payment adjustment information for the 2024 payment year. Neurosurgeons and designated practice staff may access 2022 MIPS performance feedback on the Quality Payment Program website, including final scores and 2024 payment adjustment information.
Neurosurgeons who believe there is an error in their 2024 MIPS payment adjustment may request that CMS conduct a “targeted review.” Targeted review requests must be submitted by Oct. 9. Final payment adjustments may change from now through the end of the year, depending on the results of these targeted review requests.
Click here to access the QPP Resource Library for additional information.
Neurosurgery Responds to CMS RFI on Episode-Based Payment Models
In response to a Centers for Medicare & Medicaid Services (CMS) request for information (RFI), the CNS and the AANS provided input on how best to proceed with episode-based payment models. In the letter, the CNS and AANS recommended that in developing episode-based and alternative payment models, CMS should:
- Incentivize, rather than mandate, participation;
- Involve clinical experts;
- Emphasize specialty-developed quality measures and harness the power of clinical data registries;
- Only hold physicians accountable for care decisions in their direct control;
- Abandon one-size-fits-all approaches; and
- Ensure that evaluations of cost simultaneously account for the impact on quality.
The CNS and the AANS also joined the Physician Clinical Registry Coalition in responding to the RFI, urging the agency to encourage the meaningful use of clinical data registries in any future episode-based payment model. Accordingly, the letter recommended that meaningful use of registry data should be one of the cornerstones of any innovative quality-based payment program.
CNS and AANS Comment on Hospital Outpatient and Ambulatory Surgery Center Payment Rule
On Sept. 11, the CNS and the AANS submitted comments regarding the Centers for Medicare & Medicaid Services Calendar Year 2024 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center (ASC) Payment System proposed rule. In the letter, the neurosurgical societies opposed the CMS proposal to re-adopt two previously retired quality measures that would evaluate facility procedure volume under the Hospital Outpatient Quality Reporting and ASC Quality Reporting programs. The CNS and the AANS also voiced concerns about measuring volume irrespective of quality, which could incentivize providers to perform non-indicated procedures.
Click here to read the comment letter.
Washington Committee Chair Featured in Article on Prior Authorization
Following an CNS/AANS Washington Office press release, News Medical published an article on July 4, “AANS, CNS urge CMS to finalize rules to improve prior authorization.” The article noted the CNS and the AANS joined 61 bipartisan senators and 233 members of the House of Representatives in urging CMS to finalize updates to prior authorization. The article quoted CNS/AANS Washington Committee chair Russell R. Lonser, MD, FAANS:
Our message to policymakers is simple: our patients cannot afford to wait or jump through unnecessary hoops to get care for painful, debilitating and life-threatening neurologic conditions. When finalized, these rules would remove barriers to patients’ timely access to care and allow physicians to spend more time treating patients and less time on paperwork.
Neurosurgery Mentioned in Article on Carotid Stenting Coverage in Medicare
On July 12, Medscape published an article titled “Expanded Coverage of Carotid Stenting in CMS Draft Proposal,” stating that the Centers for Medicare & Medicaid Services had issued a draft decision memo on carotid-artery stenting (CAS) that would expand Medicare coverage of the procedure and remove certain requirements for CAS facilities and operators. The proposed coverage criteria incorporate recommendations made by several societies, including the CNS and the AANS.
Neurosurgeon Authors Op-Ed on Border Wall Injuries
On July 6, The Hill published an op-ed titled, “A new crisis at the border: Traumatic injuries caused by falls from Trump’s 30-foot wall.” In the op-ed, Alexander Tenorio, MD, a neurological surgery resident at the University of California San Diego, discusses the injuries and economic burden of height extensions of U.S.-Mexico border wall barriers. “As a physician, it is my duty to reveal this unnecessary harm and strain on hospital resources. As the son of Mexican immigrants, it is my duty to continue to fight for this vulnerable population,” states Dr. Tenorio.
On July 7, Neurosurgery Blog published a cross-post to amplify the message.
Neurosurgery Blog Features Article on Traumatic Odontoid Fractures
On July 17, the Neurosurgery Blog cross-posted a recent publication in Neurosurgery, the official journal of the Congress of Neurological Surgeons. Titled “Surgery Decreases Nonunion, Myelopathy, and Mortality for Patients With Traumatic Odontoid Fractures: A Propensity Score Matched Analysis,” the article was published as part of Neurosurgery’s High-Impact Manuscript Service.
The article addresses odontoid fractures, common in elderly patients after a low-energy fall. “Given the increasing incidence of odontoid fractures with the aging population, we believe our findings could assist with neurosurgical decision-making for an increasingly common and complex problem,” the researchers say.
Click here to read the Neurosurgery Blog cross-post.
Pediatric Neurosurgeon Reflects on Job and the Post-Roe Landscape
On July 28, Dave Davies of NPR’s Fresh Air interviewed pediatric neurosurgeon John “Jay” Wellons, III, MD, FAANS, about his memoir “All That Moves Us,” which reflects on his experiences operating on children facing critical illnesses and injuries.
When asked what he thinks will happen in the post-Roe landscape, Dr. Wellons states:
I can’t tell you how much I think that this ruling is going to affect what it’s like for families to have these substantial — neurologic, cardiac, urologic — encephaloceles where the gut’s outside the body that is hard to be fixed sometimes. Like, we’re going to see a lot more of these now, and we’re going to have to, as a society, understand that we’re going to have to take care of these children. That’s our job. So, yes, I think it’s going to have an impact.
On Aug. 7, Neurosurgery Blog published a cross-post to amplify the message.
Neurosurgeons Interviewed on Spinal Procedures
On Aug. 16, Becker’s Spine Review published an interview with Anthony L. Asher, MD, FAANS, FACS, and Dom Coric, MD, FAANS. Titled “Are unnecessary spinal surgeries on the rise? Here’s why the answer might be complicated,” Drs. Asher and Coric discussed why practicing evidence-based medicine & participating in clinical outcomes registries will help prevent unnecessary spinal surgeries.
Click here to read the interview.
Neurosurgery Featured in Article about Value-Based Payment Models
On Aug. 28, MedPage Today published an article titled “CMS Facing Challenges Attracting Practices to Value-Based Payment Models.” The article noted that the Centers for Medicare & Medicaid Services (CMS) continues to face numerous challenges in attracting more fee-for-service medical practices to Medicare’s accountable care organizations (ACOs) and other value-based purchasing arrangements.
“Since the inception of Medicare value-based care programs more than a decade ago, there is still a paucity of alternative payment models available for specialty physicians, including neurosurgeons,” according to Katie O. Orrico, Esq., CNS/AANS senior vice president for health policy and advocacy. Ms. Orrico continued, “Year after year, our professional associations have urged CMS to collaborate with the physician community to develop specialty APMs, to no avail. Instead, the agency is doubling down on a one-size-fits-all approach to value-based care, focusing on primary care, chronic care management, and large ACOs.”
Neurosurgeon Authors JAMA Article on Physician Burnout
On Sept. 1, the Journal of the American Medical Association (JAMA) published an article, “Improving Health Care Quality Measurement to Combat Clinician Burnout.” In the article, neurosurgeon Anthony M. DiGiorgio, DO, MHA, FAANS, joined AMA president Jesse M. Ehrenfeld, MD, MPH, and Brian J. Miller, MD, MBA, MPH, in discussing the impacts and causes of burnout, which affects up to two-thirds of physicians.
Although the causes are multifactorial, the authors state that one of the key causes of clinician frustration is quality metrics. Administrative burdens from poorly designed systems and ineffective regulatory policies are central to clinician frustration. Improving these metrics could reduce clinician burnout, with studies indicating that physicians spend less than 15% of their day in direct patient contact.
On Sept. 7, the Neurosurgery Blog published a cross-post to amplify this important message.
Neurosurgery Blog Highlights Program to Attract Underrepresented Students to Neurosurgery
Dedicated to alleviating health care disparities, the CNS Foundation’s Pathway to Neurosurgery program encourages high school students from underrepresented groups and/or disadvantaged backgrounds to pursue a career in neurosurgery. On Sept. 11, the CNS Foundation hosted the program for the third year during the CNS 2023 Annual Meeting in Washington, DC. Recognizing this noteworthy program, the District of Columbia Mayor Muriel Bowser proclaimed Sept. 7-13 as Pathway to Neurosurgery Week.
Click here to read the Neurosurgery Blog article highlighting the Pathway to Neurosurgery program and here for the press release.
Please Share Your Social Media Handles
The CNS/AANS Washington Committee and Washington Office are working to expand their social media reach. Our goal is to increase and enhance our engagement with neurosurgeons. With nearly 125,000 total followers across the Washington Committee’s social media accounts, we have an extensive audience for you to reach.
Click here to provide us with your public social media account handles.
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