What is the level of evidence substantiating commercial payers coverage policies for total joint arthroplasty

Abstract Background The prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of healthcare stakeholders. The payers have also utilized a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level-of-evidence (LOE) of the coverage policies being utilized by commercial payers in the United States. Methods The references of the coverage policies of four commercial insurance companies were reviewed for type of document, LOE, applicability to a TJA population and success of nonoperative treatment in patients with severe degenerative joint disease. Results 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. Conclusion 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 vs. 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 towards that end through multicenter collaboration.