Declining Utilization of Percutaneous Epidural Adhesiolysis in Medicare Population: Evidence-Based or Over-Regulated?

Abstract

Background: Recent reviews have shown a reversal of growth of utilization of a majority of interventional techniques in the Medicare population post passage of the Affordable Care Act (ACA). Despite the presence of supportive evidence, there has been a significant decline in the utilization of percutaneous adhesiolysis. We hypothesize that this is most likely attributable to regulations governing interventional procedures and coverage policies. Study Design: Assessment of utilization characteristics of percutaneous adhesiolysis procedures in managing chronic low back and lower extremity pain in fee-for-service (FFS) Medicare population. Objective: To assess the utilization patterns of percutaneous adhesiolysis and correlation between regulations and declining utilization patterns. Methods: FFS Medicare data from Centers for Medicare and Medicaid Services (CMS) Physician/ Supplier Procedure Summary Master File from 2000 to 2016 was utilized. Results: From 2009 to 2016, there was a decline of 53.2% with an annual decline of 10.3%, whereas from 2000 to 2009, overall increase was 62.6% with an annual increase of 6.5% per 100,000 Medicare population. The states controlled by Noridian Medicare carrier have shown a steep decline of 100% from 2009 to 2016 due to a noncoverage policy issued by Noridian. Limitations: This analysis has not included Medicare Advantage Plans. However, an overwhelming majority of Medicare Advantage Plans do not cover adhesiolysis procedures. Conclusion: Percutaneous adhesiolysis procedures faced a steep decline in utilization from 2009 to 2016 of 53.2% and an annual decline of 10.3% per 100,000 Medicare population. This is occurring simultaneous to an increase in the evidence base. Key words: Interventional techniques, chronic low back pain, lower extremity pain, epidural injections, percutaneous adhesiolysis, post-surgery syndrome, spinal stenosis, neuroplasty