Issue link: https://beckershealthcare.uberflip.com/i/1199901
14 SPINE SURGEONS Judge dismisses lawsuit over Aetna's spine surgery coverage: 4 things to know By Angie Stewart A lawsuit accusing Aetna Life Insurance of wrongly denying coverage for lumbar artificial disc replacement surgery was dismissed by a federal judge, Bloomberg Law reported. Four things to know: 1. Aetna-insured patients Brian Hen- dricks and Andrew Sagalongos filed a class-action complaint against Aetna on Aug. 7, alleging that the insurer's prac- tice of denying coverage for lumbar arti- ficial disc replacement violated the Em- ployee Retirement Income Security Act. 2. Aetna denied coverage for the spinal surgery on the grounds that this service is "experimental and investigational," the lawsuit stated. However, the plain- tiffs argued that lumbar artificial disc replacement surgery has been FDA-ap- proved for 15 years "and is a safe, effec- tive and oen recommended procedure that has successfully treated the symp- toms of lumbar disc disease." 3. Judge Cormac J. Carney ruled that the lawsuit didn't include enough specific information. Mr. Hendricks needed to specify the health plan terms that would entitle him to benefits under ERISA, Mr. Carney said. 4. UnitedHealth and Anthem have settled similar lawsuits, according to Bloomberg Law. n CMS rules set 'dangerous precedent' for specialty reimbursement, AAOS president says By Angie Stewart T he American Association of Orthopaedic Surgeons takes issue with several changes in CMS' recently released final rules, according to a statement from AAOS President Kristy L. Weber, MD. Dr. Weber criticized CMS' decision to remove hip replacements from the inpa- tient-only list in 2020, as well as its "failure" to apply updated evaluation and man- agement values to global codes for 2021. The policies under scrutiny are outlined in CMS' 2020 Medicare Hospital Outpa- tient Prospective Payment System and ASC Payment System Final Rule, as well as its Medicare Physician Fee Schedule Final Rule. Both were published Nov. 1. Dr. Weber said the removal of hip replacements from the inpatient-only list is con- cerning given the "unintended consequences" of its decision to remove knee re- placements from the inpatient-only list in 2018. By not applying updated E/M values to global codes — despite recommendations from the medical community — "CMS is setting a dangerous precedent," Dr. Weber said. "For orthopedics, this will mean an unfair differential in future reimbursements for specialty care." In preparing for these new policies, AAOS urged CMS to trust and empower physi- cians to determine the best practice setting for their patients. The organization also asked CMS to uphold the statutory requirements of MACRA section 523(a). n Pain physician pleads guilty to accepting $140K kickbacks from Insys By Laura Dyrda K enneth Sun, MD, of Easton, Pa., pleaded guilty Nov. 22 to his role in the Insys Therapeutics kickback scheme, receiving bribes in exchange for prescribing large amounts of the company's fentanyl narcotic. Five things to know: 1. Dr. Sun pleaded guilty to receiv- ing more than $140,000 in bribes and kickbacks from Insys Therapeutics to prescribe Subsys. The payments were labeled honoraria for educational pre- sentations that Dr. Sun provided to oth- er practitioners; however, he admitted that the presentations were a sham. 2. The company would hold the educa- tional events, but the same individuals attended them multiple times, and there were some presentations attributed to Dr. Sun that he did not attend at all. 3. From 2012 to 2016, Dr. Sun admitted to soliciting and receiving the kickbacks from Insys. At the same time, he billed Medicare for more than $847,000 in Subsys prescriptions that were medical- ly unnecessary and procured through the bribes and kickbacks, according to the Department of Justice. 4. Subsys is FDA approved for cancer pain management for patients who havegrown tolerant to other pain ther- apy. However, Dr. Sun admitted to pre- scribing Subsys outside of that indica- tion. 5. In June, Insys paid $225 million to settle illegal marketing allegations re- lated to Subsys. The company's found- er and four other executives were also convicted of racketeering by a federal jury earlier this year. n