Dynesys® Dynamic Stabilization System - Payer Coverage

Coverage defines what services and procedures payers will reimburse. Coverage is usually articulated through medical policies and is payer-specific. Payers, including the Centers for Medicare and Medicaid Services (CMS) and private payers, may have different coverage policies for the same procedure. Each payer makes its own determinations of what procedures will and will not be covered.

Because coverage policies can vary by payer, we strongly recommend contacting the payer directly with questions regarding medical policies or guidelines for dynamic spinal stabilization devices. Understanding the prior-authorization requirements for fusion procedures is also recommended, as the Dynesys System is indicated only for use as an adjunct to fusion.

Currently, there are a number of payers with published non-coverage policies for lumbar dynamic stabilization devices. These payers consider dynamic stabilization devices for the treatment of disorders of the lumbar and sacral spine as investigational or not medically necessary for all indications. Please note that the published non-coverage policies are applicable to various dynamic stabilization devices and are not specific to the Dynesys System.

The following payers have published non-coverage policies for dynamic stabilization devices when utilized as an adjunct to fusion. The medical policies listed below are available on the payer's web site. We recommend verifying coverage and reviewing these policies prior to rendering services.

  • Aetna
  • BlueCross BlueShield of Minnesota
  • CareFirst BlueCross BlueShield
  • CIGNA
  • Great-West Healthcare
  • Group Health Cooperative
  • Harvard Pilgrim
  • Humana
  • Medical Health Plans
  • MVP Health Preferred Care
  • PacificSource
  • Premera
  • The Regence Group
  • United Healthcare
  • WellPoint/Anthem

Please note that this list represents payers that currently have medical policies regarding dynamic stabilization and make their policies publicly available. Other payers not listed above may have coverage policies regarding dynamic stabilization, and we suggest contacting them directly should there be any question regarding their coverage policies.

It may be possible to obtain coverage for the Dynesys System used as a pedicle screw fixation system on a case-by-case basis for some of the members of the payers listed above. A determination of medical necessity will be required and possibly necessitate peer-to-peer discussions with the payer's medical director. Some examples of members for which a non-coverage policy for treatment with dynamic stabilization devices may not apply are those individuals covered by self-insured employer group health plans and federal employees.

A self-insured group health plan (also known as a self-funded plan) is one in which the employer assumes the financial risk for providing health care benefits to its employees. Self-insured group health plans come under all applicable federal laws, including the Employee Retirement Income Security Act (ERISA). It may be prudent to contact and confirm coverage through the employer and/or the third party administrator.

The Federal Employee Program (FEP) which is a part of the Federal Employees Health Benefits Program (FEHBP) may dictate that a drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational and therefore, coverage eligibility may be assessed on the basis of medical necessity. Contact the FEP to confirm coverage and guidelines for dynamic stabilization devices used as a pedicle screw fixation system.

Medicare has no established coverage policies regarding dynamic stabilization devices used as an adjunct to fusion or otherwise. Medicare will determine case-by-case coverage determinations based upon the necessity and medical reasonability of the treatment for a Medicare beneficiary.

Because of the various issues with private payer coverage for the Dynesys System, the remainder of this reimbursement kit provides guidance regarding typical payer processes including insurance verification, prior-authorization and appealing denied claims. These processes can be confusing and will vary by payer. However, following the guidance provided in this reimbursement kit may help to facilitate achieving case-by-case coverage for the Dynesys System when used as an adjunct to fusion consistent with its indication.

Download Complete Reimbursement Kit PDF

Reimbursement Kit Chapters

Overview
Insurance Verification Process
Prior Authorization Process
Coding Guidance
Appeals
FAQs
Sample Letters
Disclaimer