Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

Sudah, Suleiman Y.; Faccone, Robert D.; Imam, Nareena; Patankar, Aneesh; Manzi, Joseph E.; Menendez, Mariano E.; Nicholson, Allen D.

doi:10.1016/j.jse.2023.04.014

Cited by 1 publication

(6 citation statements)

References 130 publications

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“…They also found that primary journal articles (n = 70; 59.3%) were the most frequently cited and that most references were of level IV evidence (n = 60; 52.2%). 17 Only 6 (5.2%) of the sources they analyzed were level I or II evidence. 17 Of the 238 unique references analyzed in our study, only 4 (1.7%) were level I evidence and 24 (10.1%) were level II.…”

Section: Discussionmentioning

confidence: 99%

“… 17 Only 6 (5.2%) of the sources they analyzed were level I or II evidence. 17 Of the 238 unique references analyzed in our study, only 4 (1.7%) were level I evidence and 24 (10.1%) were level II. Thus, it appears that commercial payers tend to support their coverage policies for TAA with low level evidence.…”

Section: Discussionmentioning

confidence: 99%

“…Analysis of insurance coverage criteria for these arthroplasty procedures reveals they are closely related and all require some period of conservative treatment before insurance companies with coverage arthroplasty. 1 , 17 Previous research has shown that this period of conservative management is not well supported in the hip, knee, and shoulder arthroplasty literature. 1 , 17 The same appears to be true for TAA.…”

Section: Discussionmentioning

confidence: 99%

“…Previous studies in the total joint arthroplasty (TJA) and total shoulder arthroplasty (TSA) literature have found that such requirements for attempted nonoperative management are poorly supported both by the references in the coverage policy document and by available literature on the subject. 1 , 17 More generally, these same studies have shown that the references used to support all commercial insurance coverage criteria for TJA and TSA tend to be of low level of evidence. 1 , 17 …”

Section: Introductionmentioning

confidence: 96%

“… 1 , 17 More generally, these same studies have shown that the references used to support all commercial insurance coverage criteria for TJA and TSA tend to be of low level of evidence. 1 , 17 …”

Section: Introductionmentioning

confidence: 96%

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Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty

Kotlier,

Fathi,

Ong

et al. 2024

Foot & Ankle Orthopaedics

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Background: Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies. Methods: The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria. Results: Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria. Conclusion: This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered. Level of Evidence: Level IV, review.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%