A California federal judge last week granted class status certification to a lawsuit filed against Aetna that claims the insurer broke federal law by denying coverage for lumbar artificial disc replacement surgery.
The class action suit alleges that Aetna classifies the spinal surgery as "experimental" and "investigational" and in many cases would not pay for beneficiaries' procedures.
According to the lawsuit, more than 200 patients have been denied coverage for the procedure on the same grounds.
Plaintiffs are suing under the Employee Retirement Income Security Act—which sets standards for private health plans—for Aetna's "denial of plan benefits and clarification of rights" and "breach of fiduciary duty."
The individuals are suing as part of a class covered by an Aetna employer-sponsored plan.
Among other forms of relief, the lawsuit is asking for an injunction that would require Aetna to retract its policy on lumbar ADR cases, which states the surgery is experimental or investigational due to a lack of evidence on prosthetic lumbar discs' effectiveness. Lumbar ADR is a newer form of spinal disc procedure that involves replacing a diseased spinal disc with an artificial one, and it is an alternative method of treatment to spinal fusion.
Aetna did not provide comment on the lawsuit by deadline.
The lawsuit's two main plaintiffs, who have disc disease in their lower spine causing pain and immobility, sought out Lumbar ADR at the recommendation of surgeons after medication and corrective exercises failed to improve their condition.
A 2018 report in the Journal of Orthopaedic Surgery and Research found that the satisfaction rate for Lumbar ADR patients was between 75.5 to 93.3% in various studies, and the procedure had a clinical success rate of 53.7 to 71.4%. The surgery costs anywhere from $30.000 to $100,000, depending on the location.
