Why Insurance Companies Pay For Opioids But Not For Less Risky Pain Treatments : Shots - Health News It seemed like such a good idea: Use cold therapy to reduce the need for opioid painkillers after shoulder surgery. But this woman's insurance company said no dice.
NPR logo The Insurance Company Paid For Opioids, But Not Cold Therapy

The Insurance Company Paid For Opioids, But Not Cold Therapy

Lauren Kafka rented a machine that delivered cold water and compression to manage pain after rotator cuff surgery. Her insurance company said it wasn't medically necessary and refused to pay for it. Courtesy of Alexander C. Kafka hide caption

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Courtesy of Alexander C. Kafka

Lauren Kafka rented a machine that delivered cold water and compression to manage pain after rotator cuff surgery. Her insurance company said it wasn't medically necessary and refused to pay for it.

Courtesy of Alexander C. Kafka

As a lifelong racket-sports fanatic, I've dealt with shoulder pain for decades, treating it with bags of frozen peas, physical therapy, cortisone shots and even experimental treatments like platelet-rich plasma. Eventually, however, the soreness prevented me from handling daily-living tasks like pulling a bottle of olive oil off the top shelf of my kitchen or reaching to the back seat of my car to grab my purse. Even low-impact activities such as swimming freestyle hurt a lot. Sleeping also got tougher. After MRI showed two full-thickness rotator-cuff tears, I finally called a surgeon.

My tennis-team pals who had survived the operation gave me valuable advice: sewing Velcro down the front of half a dozen T-shirts to avoid having to put them over my head; borrowing an electric recliner chair in which to sleep for the first six weeks; buying pump bottles of shampoo and conditioner that I could dispense with my left hand; and removing safety caps from medications. To manage the pain after surgery, they also suggested renting an ice machine.

I've had bad side effects from anti-inflammatory painkillers and my goal was to take as few opioids as possible, so the ice machine sounded appealing. Two physical therapists recommended models with a mechanical pump that circulates chilled water. They said to be sure to use one that also provides compression, which reduces stiffness, swelling and pain in the joint.

My surgeon, Dr. David Lutton at Washington Circle Orthopaedic Associates in Washington, D.C., agreed that an ice machine was a great idea, saying via email that cool-therapy devices help manage postoperative discomfort "while minimizing the physical and cognitive side effects of pain medications such as narcotics."

Unfortunately, my doctor's surgical coordinator told me I'd have to pay to rent one on my own because my insurance wouldn't cover it. The best price I could find was $250 for a three-week rental of a Game Ready machine from Orthosport, a distributor in Virginia. This price sounded high, but I was relieved that the surgery and physical therapy would be covered, and my fears about excessive post-operative pain outweighed my economic concerns. Despite the pessimistic warnings about coverage, I asked Orthosport to submit the bill to Cigna.

During the first few weeks after surgery, I tried to take opioid painkillers only sparingly, relying mostly on the ice machine. I sometimes left it on throughout the night while I tried to sleep in my sling in a borrowed recliner, and it frequently relieved the discomfort enough that I could sleep for four to five consecutive hours.

After three weeks, I decided that it was worth paying an additional $250 out of pocket to keep the machine for another three weeks. Unlike the type of physical therapy I was used to for sports injuries — the kind that immediately reduces pain — the therapy regimen after rotator-cuff surgery is absolutely excruciating for several weeks, sometimes months.

The ice machine helped me taper my drug use from oxycodone to tramadol, a less powerful painkiller, and now I'm using primarily acetaminophen. More than six weeks after surgery, I'm still relying on the Game Ready machine and dread the day when I'll have to give it up.

A couple of weeks into my recovery period, Cigna denied my claim. I appealed by explaining that the ice machine was medically necessary because I am unable to take anti-inflammatories, and the unit was providing a safe and effective alternative to opioids, which had given me several adverse side effects when I'd used them in the past. It was also much easier to work without having to hold, strap or tape ice packs on the front, back and side of my shoulder. Cigna denied my appeal and told me that the ice machine was a "personal convenience item" and therefore a noncovered expense.

I was determined to find out why an insurer wouldn't pay for the ice machine my doctor prescribed when it had covered the oxycodone. This drug and other painkillers have fueled the opioid epidemic, which according to the National Center for Health Statistics killed more than 64,000 people in the U.S. in 2016. I also was curious to find out why insurance companies weren't convinced about the effectiveness of ice machines, so in between shoulder exercises and tutoring, I switched gears and went into reporter mode.

"Physician or patient anecdotes of good results are the least compelling evidence to payers," Dana Macher, vice president of reimbursement and market access at Avalere Health, a health care consulting firm, told me in an email. "Bottom line is that it is all about the evidence. The gold standard is multiple randomized controlled clinical trials. Devices rarely have this information due to the fact that they do not (many cannot) invest the sums of money required. Lower-quality data or no published data is likely to result in non-coverage."

Then I contacted the people at Game Ready, who cited five studies that show benefits for knee- and hip-surgery patients provided by this system compared with passive ice therapy. These benefits include reduced consumption of narcotics; improvement of measurable physical therapy milestones; reduced pain and swelling; increased postoperative function; and improved patient satisfaction with the recovery process. I sent my insurance company links to the abstracts for these studies.

Cigna replied. "Our coverage policies for medications, medical procedures and medical devices are based on an extensive examination of peer-reviewed clinical studies, journal articles and guidelines from professional medical societies," wrote Dr. Julie Kessel, head of Cigna's Coverage Policy Unit, via email. "Currently, the clinical evidence for the Game Ready device does not support its coverage, as its benefits over applying ice to the injured area have not yet been established. However, our coverage policies are typically reviewed annually and can be updated based on new clinical evidence."

Tomasina Barton, senior vice president of marketing at Game Ready, says she doesn't know whether private insurance companies have seen her company's clinical studies or use them in relation to their coverage policies.

"Holistically, we would want an insurance company to look at the overall quality and cost of care," she says. "Hospitals and providers are looking at where the patient does best, and patients are recovering better at home."

Insurance didn't cover the cost of the Game Ready ice machine, but it did cover the cost of opioid painkillers. Courtesy of Alexander C. Kafka hide caption

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Courtesy of Alexander C. Kafka

Insurance didn't cover the cost of the Game Ready ice machine, but it did cover the cost of opioid painkillers.

Courtesy of Alexander C. Kafka

Insurance coverage for home-care ice machines varies by state and individual policy, according to Barton, but private insurers typically refuse to cover them.

Despite the failure of my appeal to Cigna, several health care professionals told me that appeals are important catalysts for change in the insurance industry even if they don't produce immediate results.

"The system does rely on people appealing to some degree," says Dan Mendelson, president of Avalere Health. "Insurance companies will re-review the evidence where there are a lot of appeals, but devices and procedures can be considered experimental for decades, and without peer-reviewed literature, insurance companies won't cover them."

Although the use of cryotherapy devices is still considered experimental by many insurance companies, doctors in other specialties besides orthopedics agree that methods to manage pain without opioids should be a top priority.

"The medical community, insurance companies, and patients should all be doing everything in our power to limit our reliance on opioids," says Dr. Marian Sherman, an anesthesiologist at George Washington University Hospital who has a special interest in opioid-sparing strategies for postoperative pain control. "This means capitalizing on all available pain-reducing modalities. Icing machines have been demonstrated to work, and when used appropriately, the side-effect profile is zero. We can't say this about a single medication."

Here's my conclusion: If insurance companies want to play a part in the solution to the opioid crisis, they are going to need to start thinking outside the traditional boxes. The manufacturers of these cryotherapy devices need to provide insurance companies with more convincing peer-reviewed data of their benefits, including the devices' role in getting patients out of rehab and back to work sooner, which will cut costs in the long run. Patients need to let their doctors and insurance companies know that they want insurance coverage for safe alternatives to narcotics — even if it means going through the time-consuming appeal process.

"The more information we can get out to the public, the more demand there will be for the ice machines," Lutton wrote in his email to me. "Ultimately, that's the only way that the insurance companies will end up paying for them."


Lauren Kafka is a freelance writer, editor and English tutor and founder of Kafka Consulting in Bethesda, Md. She hopes to be back on the tennis court next summer. She's on Twitter: @LaurenKafka