Nicotine replacement therapy and elective spinal fusion eligibility: a national analysis of insurance policy language

Smoking is a well-established risk factor for impaired spinal fusion, leading many insurers to require preoperative abstinence. Nicotine replacement therapy (NRT) supports smoking cessation without consistently demonstrating detrimental effects on spinal fusion outcomes. Nonetheless, many insurance policies for elective spinal fusion surgery treat NRT use as equivalent to active smoking, creating potential barriers for patients attempting evidence-based cessation. This study evaluated the clarity and nicotine specificity of insurer elective spinal fusion policies nationwide and identified factors associated with vague or restrictive language.

Active spinal fusion coverage policies were identified using Policy Reporter. A total of 107 policies from 64 insurers across 49 states were analyzed. Policies were categorized based on clarity of cessation requirements, verification methods, and whether NRT use was distinguished from tobacco use. Insurance market share data were incorporated to estimate potential population-level relevance. Logistic regression and supervised machine learning models were used to identify policy characteristics predictive of vagueness or NRT-unfriendly language.

Sixty-six policies (62%) required preoperative cessation, of which 64% were NRT unfriendly and 29% lacked clear cessation timelines. Thirty-two percent of the US insurance market is governed by plans with NRT-unfriendly language, with 24 states having at least one of the top 2 major payers applying such language. Medicare Advantage plans had significantly lower odds of being NRT friendly (OR 0.06, p = 0.001). Machine learning models predicted NRT friendliness with 82.2% accuracy (area under the curve 0.80), with Medicare Advantage status and policy geographic scope among the strongest predictors.

A substantial portion of spinal fusion coverage policies either lack clarity or treat NRT use equivalently to smoking, despite limited evidence that therapeutic nicotine exposure adversely affects fusion. These patterns affect a meaningful share of insured patients and may introduce preventable variability in authorization workflows. Clearer, standardized policy language that distinguishes NRT from tobacco use may better reflect emerging evidence, support patient-centered cessation strategies, and promote alignment between insurance criteria and clinical practice.