#United States #New Orleans #Spine Surgery #AAOS #Prior Authorization

Study Shows Impact of Prior Authorization on Spine Surgery

In a groundbreaking study presented at the 2026 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), researchers found that the requirement for prior authorization (PA) for elective spine surgery not only delays necessary procedures for patients suffering from degenerative spine disease but also fails to provide any cost-saving benefits to healthcare payers. This study comes at a time when both public and private health plans are increasingly utilizing PA in an effort to manage rising medical costs.

According to the Kaiser Family Foundation, a staggering 99% of patients in the U.S. with insurance coverage—whether through public, private, or employer-sponsored plans—are subjected to PA rules for costly procedures including surgeries, imaging, and high-tier medications. The consequences of these requirements can be dire; when care is denied, patients often face out-of-pocket expenses, which can drive them into medical debt—a significant factor in personal bankruptcy cases across the nation.

Dr. Rob Turk, an orthopaedic surgery resident at Carolinas Medical Center in Charlotte, North Carolina, led the study. “We aimed to explore how PA aligns with the principles of value-based care,” he noted. This exploration included identifying patterns in the denials of recommended spine procedures, assessing if the PA process supports evidence-based medical care or serves as a barrier to timely treatment.

Collaborating with researchers from the OrthoCarolina Research Institute, Dr. Turk analyzed over 7,000 patient records spanning from January 2021 to December 2024. The focus was on adults needing elective surgeries for degenerative spine conditions affecting either the lumbar or cervical regions. Out of this cohort, insurance companies denied PA for 460 patients—representing about 7% of the total cases reviewed.

Key Findings From the Study

The study unearthed significant insights regarding the reasons behind the denials of elective spine surgical procedures:

• - Types of Denials: The most common issues arose from needing documentation such as completed physical therapy sessions or insurance determinations around medical necessity.
• - Specifics of Denials: For instance, 15.4% of denials were for stand-alone lumbar decompression procedures, while 27.8% were for lumbar decompression combined with instrumented fusion.
• - Documentation Issues: In a notable 30% of denials (138 cases), coverage was declined due to inadequate documentation of six weeks of physical therapy.
• - Decision-Making Criteria: About 26.5% of the denied procedures were deemed not medically necessary by the insurer. Additionally, there were 69 cases where evidence of attempted cessation by smokers was required but not provided.
• - Appeals Process: Nearly one-third of the initial denials (30.9%) necessitated a cumbersome peer-to-peer (P2P) appeal process, further delaying patient care.
• - Delayed Surgeries: Ultimately, a substantial 81.3% of patients (374 individuals) who had their surgeries initially denied later proceeded to have the operations—only after an average delay of 15.7 days, compounded by a standard deviation of 33 days.

Dr. Turk poignantly addressed the ramifications of these delays: “Patients were forced to endure debilitating pain that interfered with their work, family, and social engagements. Meanwhile, health plans were spending on ineffective treatment options rather than facilitating timely surgical interventions that could have alleviated their suffering early on.”

Future Implications

As the U.S. population continues to age, the demand for spine-related surgeries is anticipated to grow significantly. Dr. Turk warns that factors such as workplace injuries resulting from increased oversight of productivity can exacerbate this trend, coupled with the potential relaxation of federal regulations regarding workplace safety.

In response to the issues raised by this study, the AAOS has been advocating for legislative reforms aimed at streamlining the PA process and improving transparency, while ensuring that patients maintain access to necessary treatments promptly. The organization encourages physicians and patients to participate actively in discussions with policymakers to drive this change.

For more information on AAOS advocacy efforts and resources regarding prior authorization, visit the AAOS Advocacy Action Center at aaos.org/advocacy.