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Insurance payer policies for subacromial balloon spacer coverage utilize poor quantity and quality of references
Eric H Lin1, Mayilone Sathialingam1, Avinash Iyer1
1Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
Background:
Prior studies of orthopedic procedures have shown poor quality of evidence supporting commercial payer coverage policies. This study aimed to analyze commercial payer policies for balloon spacer coverage to determine the quality and quantity of references cited in these policies.
Methods:
Eleven major national health insurance payers (Aetna, Anthem, Centene Corp. Cigna, Health Care Services Corp., Highmark, Humana, Kaiser Permanente, United Healthcare, The University of Pittsburgh Medical Center Health Plan, and WellCare Health Plans) were identified in July 2024 for this study. Of these payers, only 4 (Aetna, Cigna, Humana, and United) included publicly accessible policies related to coverage for balloon spacers for treatment of massive rotator cuff tears. References were screened for any mention of "subacromial balloon spacer" AND "massive rotator cuff tear." Included references were evaluated for reference type, level of evidence (LOE), balloon spacer efficacy, and failure of conservative management.
Results:
Twenty-eight unique references were identified. Eleven articles (39.3%) were primary journal articles, 11 (39.3%) were reviews, 2 (7.1%) were miscellaneous articles, 2 (7.1%) were unable to be accessed, one (3.6%) was a society guideline, and one (3.6%) was an expert opinion. Only 2 (7.1%) studies were LOE I or II. The majority of references had a LOE IV (n = 18, 64.3%). There were 15 (53.6%) studies that demonstrated improvement in at least one outcome measure. Seven (25%) of the studies did not have definitive conclusions or recommendations for balloon spacer use. Conservative treatment failure was documented in 17 (60.7%) of the references, with only 5 mentioning a specific minimum time period of conservative treatment.
Conclusion:
Payer coverage policies for subacromial balloon spacer lack sufficient quality and quantity of references. More high-quality literature is needed to support these policies and payers should continually update their policies with this literature. Increasing public access and availability to coverage policies can improve transparency.
