Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA.
Department of Orthopaedic Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA.
J Arthroplasty. 2021 Aug;36(8):2665-2673.e8. doi: 10.1016/j.arth.2021.03.036. Epub 2021 Mar 22.
The prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of health care stakeholders. The payers have also used a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level of evidence of the coverage policies being used by commercial payers in the United States.
The references of the coverage policies of four commercial insurance companies were reviewed for type of document, level of evidence, applicability to a TJA population, and success of nonoperative treatment in patients with severe degenerative joint disease.
282 documents were reviewed. 45.8% were primary journal articles, 14.2% were level I or II, 41.2% were applicable to patients who were candidates for TJA, and 9.9% discussed the success of nonoperative treatment in patients who would be candidates for TJA.
Most of the references cited by commercial payers are of a lower level of scientific evidence and not applicable to patients considered to be candidates for TJA. This is relatively uniform across the reviewed payers. The dearth of high-quality literature cited by commercial payers reflects the lack of evidence and difficulty in conducting high level studies on the outcomes of nonoperative versus operative treatment for patients with severe, symptomatic osteoarthritis. Patients, surgeons, and payers would all benefit from such studies and we encourage professional societies to strive toward that end through multicenter collaboration.
全关节置换术（TJA）在美国的流行引起了医疗保健利益相关者的关注。支付方也使用了各种策略来规范这些程序的医疗必要性。本研究的目的是检查美国商业支付方使用的覆盖政策的证据水平。
审查了四家商业保险公司的覆盖政策的参考文献，以了解文件类型、证据水平、对 TJA 人群的适用性以及严重退行性关节疾病患者非手术治疗的成功率。
共审查了 282 份文件。45.8%是原发性期刊文章，14.2%是 I 级或 II 级，41.2%适用于 TJA 候选患者，9.9%讨论了 TJA 候选患者非手术治疗的成功率。
商业支付方引用的参考文献大多是科学证据水平较低且不适用于被认为是 TJA 候选患者的患者。这在被审查的支付方中相对一致。商业支付方引用的高质量文献匮乏，反映了缺乏针对严重、有症状的骨关节炎患者非手术与手术治疗结果的高质量研究，这对患者、外科医生和支付方都有益。我们鼓励专业协会通过多中心合作努力实现这一目标。
