Medicare Advantage Update: Saga Continues
As is widely recognized, Medicare Advantage co-pays continue to increase, while coverage policies are becoming increasingly restrictive. At the same time, CMS continues to provide substantial bonuses to Medicare Advantage plans and appears to be moving toward broader adoption of Medicare Advantage, potentially through automatic enrollment mechanisms that may limit choices for Medicare beneficiaries.
Included below is an update regarding CarolinaEast Medical Center and its decision to discontinue participation with Blue Cross Blue Shield and UnitedHealthcare Medicare Advantage plans. This information was provided by Giovanna Garcia.
CarolinaEast Medical Center’s decision to drop Blue Cross Blue Shield and UnitedHealthcare Medicare Advantage plans after describing payment policies, denials and reimbursement delays as “financially and operationally unsustainable” for the hospital.
CarolinaEast is part of a growing national trend.
Hospitals and health systems across the country are increasingly severing ties with Medicare Advantage plans, citing growing frustration with prior authorization delays, claims denials, and slow reimbursement processes.
- Becker’s Hospital Review reports that 21 health systems dropped Medicare Advantage plans in 2026 amid growing reimbursement and operational disputes.
With Medicare Advantage now covering 55% of eligible Medicare beneficiaries nationwide — more than 35 million seniors — these disputes are becoming increasingly consequential not only for providers and payers, but also for patients who could lose access to care as more hospitals reconsider participation in Medicare Advantage networks.
Providers say the issue is no longer just whether claims are eventually paid — it’s the operational burden required to get paid at all.
- A March 2026 AHA report found hospitals spent $43 billion in 2025 pursuing payments tied up in denials, prior authorizations, and repeated documentation requests.
Many claims are ultimately reimbursed, but only after repeated follow-ups, appeals, resubmissions, coding corrections, and manual intervention across revenue cycle teams.
MedEvolve refers to this growing operational burden as the “denials tax” — the cumulative rework, follow-up activity, and administrative effort required to move claims from submission to payment.
According to Matt Seefeld, CEO of MedEvolve, denial rates alone fail to capture the true operational strain hospitals are facing.
“A denial rate only measures the outcome,” Seefeld says. “It doesn’t measure how much work it actually takes to recover reimbursement. A claim may be reimbursed, but if it required five or six staff interactions to get there, the organization has absorbed a real operational cost.”
Seefeld can speak to what’s driving the growing backlash against Medicare Advantage plans, why hospitals are increasingly describing payer relationships as financially and operationally unsustainable, and how many organizations are beginning to rethink denial rates as a standalone revenue cycle KPI.
Cigna to Cover Spinal Cord Stimulation for Diabetic Peripheral Neuropathy
Diabetic peripheral neuropathy is a covered condition by Medicare and many other insurers however, Cigna has incorporated into the new policy effective August 4, 2026 to cover diabetic peripheral neuropathy when all the criteria are met as follows:
Trial
A short-term trial (i.e., at least [5] days) of a non-high-frequency or high-frequency (HF10 SCS) dorsal column spinal cord stimulator is considered medically necessary when ALL of the following criteria have been met:
- Performed for the treatment of chronic, intractable pain secondary to diabetic peripheral neuropathy in the lower extremities
- Symptoms include BOTH of the following:
- lower extremity neuropathic pain present for >12 months
- pain is rated at least VAS ≥5
- Ineffective pain relief with or intolerance to at least TWO of the following:
- anticonvulsants
- tricyclic antidepressant
- SNRI (serotonin-norepinephrine reuptake inhibitor)
- opioids
- If taking opioids, the opioid use is ≤100MME (morphine milligram equivalent) per day.
- Hemoglobin A1c (HbA1c) <10% within three (3) months prior to trial
- There are no other medical diagnoses (e.g. chronic inflammatory demyelinating polyneuropathy [CIDP]; Hepatitis B; HIV; Lyme disease; chemotherapy or vitamin deficiency induced neuropathy) that are concordant with the presenting symptoms, signs, and results of relevant studies (e.g., imaging, electrodiagnostic testing, laboratory testing, etc.).
- Attestation by a behavioral health provider (i.e., a face-to-face or virtual assessment [with or without psychological questionnaires and/or psychological testing]) reveals no evidence of inadequately controlled mental and/or behavioral health conditions/issues (e.g., substance use disorders, depression, or psychosis) that would impact perception of pain, and/or negatively impact the success of a SCS or contraindicate placement of the device
Permanent Implant
Permanent implantation of a non-high-frequency or high-frequency (HF10 SCS) dorsal column spinal cord stimulator is considered medically necessary when BOTH of the following criteria have been met:
- Must meet ALL criteria for a short-term trial spinal cord stimulator as noted above.
- There has been documented pain relief of at least 50% during a short-term trial of SCS.
ASIPP Sends Letter Supporting H.R. 8163, the Provider Reimbursement Stability Act
The American Society of Interventional Pain Physicians has submitted a formal letter to Greg Murphy, MD, sponsor of H.R. 8163, the Provider Reimbursement Stability Act, expressing strong support for the legislation.
In the letter, ASIPP highlights ongoing concerns related to physician reimbursement and patient access to care, including:
• Declining reimbursement: Physician payment has decreased by 33% since 2001 when adjusted for inflation, with additional 2% sequestration cuts each year and looming 4% PAYGO cuts each year based on the Congressional Budget Office report.
• Rising practice costs: Medical inflation has significantly outpaced general inflation, with healthcare costs increasing by 121.3% compared to 86.1% for consumer goods and services. Practice costs have increased 56% from 2001 to 2025, while reimbursement has declined 33% overall and 41% for interventional pain physicians, with supply costs rising 78%.
• Access to care challenges: Current Medicare reimbursement policies are contributing to the closure of community-based practices, which is reducing patient access to high-quality interventional pain management services—particularly in the ambulatory surgery center (ASC) setting.
ASIPP emphasizes that H.R. 8163 would help stabilize physician reimbursement by modernizing Medicare payment policies, including increasing the budget neutrality threshold, indexing it to the Medicare Economic Index (MEI), and ensuring more frequent updates to practice expense inputs used in RVU calculations.
The letter underscores the importance of supporting independent physician practices to ensure continued access to high-quality, evidence-based pain care.
ASIPP: Why It Matters, What We Do, and How We Lead
Why was ASIPP created—and how has it evolved? This video explores the origin, early development, and history of ASIPP.
Aetna Now Covers Peripheral Nerve Stimulation for Chronic Pain
In a policy published by Aetna last week, entitled Peripheral Electrical Nerve Stimulation for Pain Number: 0011, Aetna describes the coverage conditions for peripherally implanted nerve stimulators as follows:
Aetna considers peripherally implanted nerve stimulators (e.g., Curonix Freedom PNS System, Nalu PNS System, SPRINT PNS System, StimRouter System) medically necessary DME for treatment of members with intractable neuropathic pain when all the following criteria are met.
a. Member has chronic intractable pain, refractory to other methods of treatment (e.g., analgesics and other medications (including TCAs, SSRIs, SNRIs and antiseizure medications, where appropriate), physical therapy (in-person for at least 6 weeks in the past year), local injection, surgery); and
b. Member is not addicted to drugs (per American Society of Addiction Medicine guidelines); and
c. There is no psychological contraindication to peripheral nerve stimulation; and
d. There is objective evidence of pathology (e.g., electromyography/nerve conduction studies and diagnostic blocks of the specific affected nerve(s)); and
e. Trial of percutaneous stimulation was successful (resulting in at least a 50% reduction in pain for a minimum of 3 days). Note: If a peripheral nerve stimulation trial fails, a repeat trial is not medically necessary unless there are extenuating circumstances that lead to trial failure. Trials will be limited to four leads with maximum of 16 contacts.
You can access the updated policy here: Aetna Policy
As you all know, ASIPP has been focused and working on coverage of peripheral nerve stimulators. Enclosed, please see the letter sent to HCSC Policy Review on October 7, 2025.
Humana to Cover Spinal Cord Stimulators for Non-Surgical Back Pain
After numerous attempts by various stakeholders, Humana has issued a policy covering spinal cord stimulators for non-surgical back pain. We are hoping that others will follow suit.
Please see the Humana Coverage Policy, along with ASIPPs letter to Humana related to spinal cord stimulators.
ASIPP Advocacy Update:
Recent Letters on Coverage and Physician Payment Policy
ASIPP recently submitted several letters on key issues affecting patient access to care and the sustainability of independent physician practices.
Clinical Input to Cigna on Peripheral Nerve Stimulation (PNS) Coverage
ASIPP submitted input to Cigna regarding their position on Peripheral Nerve Stimulation (PNS). The letter highlights current clinical evidence, peer-reviewed research, and ASIPP’s evidence-based guidelines supporting PNS as an established treatment option for appropriately selected patients with chronic pain.
ASIPP requested that Cigna reconsider the “not medically necessary” designation for Peripheral Nerve Stimulation, update Policy #0539 to reflect PNS as medically necessary for appropriate indications, and consider precedents from other payers such as Aetna, BCBS Alabama, and Medicare MACs.
Read the full letter:
https://asipp.org/letter-to-cigna-medical-policy-department-re-clinical-input-regarding-cignas-peripheral-nerve-stimulation-pns-medical-coverage-policy-0539-2-11-2026/
Coverage Consideration for the MILD Procedure for Lumbar Spinal Stenosis
ASIPP submitted letters to Elevance Health, Aetna, UnitedHealthcare, Humana, and Cigna supporting coverage for the MILD Procedure (Minimally Invasive Lumbar Decompression) for patients with lumbar spinal stenosis and neurogenic claudication. The letter highlights clinical evidence, FDA clearance, and real-world outcomes demonstrating the safety and effectiveness of this minimally invasive treatment option.
ASIPP also encouraged these payers to adopt favorable coverage policies aligned with newly approved Category I CPT codes effective January 1, 2026, to help ensure patient access to this evidence-based procedure.
Read the full letter:
https://asipp.org/letter-regarding-coverage-consideration-for-the-mild-procedure-for-lumbar-spinal-stenosis-with-neurogenic-claudication-2-25-2026/
Medicare Physician Fee Schedule and Impact on Independent Practices
ASIPP submitted a follow-up letter to The Honorable Chairman James Comer, Chairman, House Oversight Committee; The Honorable Chairman Brett Guthrie, Chairman, Energy and Commerce Health Subcommittee; Senator Bill Cassidy, MD, Chairman, Committee on Health, Education, Labor, and Pensions; The Honorable Chairman Mike Crapo, Chairman, Senate Finance Committee; and Senator Marsha Blackburn regarding concerns about the Medicare Physician Fee Schedule and its impact on independent physician practices.
The letter outlines several policy issues, including proposed reductions to practice expense reimbursement, the need to reinstate broader telehealth access, concerns regarding the Ambulatory Specialty Model (ASM), and the reversal of proposed efficiency cuts tied to assumptions about AI-driven documentation improvements.
ASIPP urged policymakers to examine these issues through hearings and policy review, noting the potential impact on physician reimbursement, patient access to care, and the stability of independent medical practices.
Read the full letter:
https://asipp.org/letter-regarding-follow-up-to-medicare-physician-fee-schedule-damages-independent-practices-letter-1-12-2026/
Telehealth services extended through December 2027
The House and Senate have both passed and the President signed the federal spending package, which includes HHS funding and an extension of telehealth services through December 2027.
This legislation is effective retroactively as of February 1, 2026. As a result, there is no lapse in telehealth coverage that would have otherwise occurred following the January 31, 2026, expiration under the continuing resolution. In addition, the continuing resolution has been extended for an additional two weeks and continues to include telehealth services. We have been advised that there will be no disruption in telehealth reimbursement, and that all claims will be paid retroactively.
Please see the enclosed document for the specific legislative language included in the bill.
Extension of the telehealth provisions has been one of the major focuses of ASIPP’s efforts. Over the past several months, we have worked closely with Chairman Guthrie, Chairman Comer, and Chairman Cassidy to advance this initiative. ASIPP is very pleased to have secured this outcome—while mid-term rather than permanent, the two-year extension provides important continuity and stability. The language remains unchanged, with the extension being the primary modification, as outlined in the enclosed text.
Thank you for your continued assistance and cooperation. We also extend our sincere appreciation to our congressional supporters who helped make this significant achievement possible.
Bibliometric Analysis of Musculoskeletal RFA Research Identifies Dr. Laxmaiah Manchikanti and Dr. Steven P. Cohen as Leading Authors, with Pain Physician and Pain Medicine Among the Most Influential Journals
A recent article in Pain Physician titled “Radiofrequency Ablation for Musculoskeletal Pain: A Bibliometric Analysis of Global Research Trends (2000–2024)” (Pain Physician 2025; 28:S157-S168) examines the research landscape surrounding radiofrequency ablation (RFA) for musculoskeletal pain. The analysis identifies Pain Physician as the most relevant journal in this field, with Pain Medicine ranked as the second most relevant source.
Key findings and related bibliometric rankings include:
- Laxmaiah Manchikanti
- Identified as one of the most influential authors based on sustained productivity and citation impact, with contributions shaping the evidence base for spinal and genicular nerve interventions (Pain Physician 2025; 28:S157-S168)
- Ranked #1 globally for randomized controlled trials in chronic pain therapy spanning 1989–2024 (Medicine, 2025; 104:39)
- Ranked #1 among the most cited studies on epidural steroid injections (PM&R Sciences, 2025; 292-297)
- Dr. Steven P. Cohen
- Recognized for high citation impact and influence in musculoskeletal RFA research (Pain Physician 2025; 28:S157-S168)
For detailed data, please refer to the full article:
https://www.painphysicianjournal.com/current/pdf?article=ODA5Mg%3D%3D
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