Stealth Guided and Robotic Assisted Surgeries – Coming to an MSA Near You?

CMS, Medicare Set-Asides on November 29, 2016
Posted by Erin O'Neill, PA-C, JD

Over the past several years, there have been significant advances in surgical techniques across all fields of medicine. Two of these advances, robotic assisted surgery and stealth guided surgery have gained popularity as the technology becomes available at increasing numbers of hospitals across the country.

Robotic assisted surgery had its beginnings in 1985; however, in 2000, the da Vinci surgery system changed the face of robotic assisted minimally invasive surgery when the Federal Drug Administration (FDA) approved the comprehensive system of surgical instrumentation, cameras and tools for use in general laparoscopic surgery. As outlined on the da Vinci Surgery website, with the magnified three dimensional high definition vision system and tiny wristed instruments that bend and rotate further than the human hand, surgeons are able to operate with enhanced vision, precision and control through far tinier incisions than ever imagined in the past. Currently, the da Vinci surgical system is utilized for urologic, cardiac, gynecologic, otolaryngologic, thoracic, general and colorectal procedures. Over three million procedures have been performed utilizing the da Vinci system worldwide.  Similar robotic assisted surgical systems have been developed to assist with specific orthopedic and neurologic procedures and are gaining in popularity as well.

In conjunction with robotic assisted surgery, is the development of stealth guided or computer assisted surgical navigation systems. Pre-operative ultrasound, CT and MRI scans can be utilized to create a three dimensional model of the patient to assist with surgical planning. During the procedure, the surgeon utilizes the imaging technology to better visualize the patient’s anatomy. Specialized surgical instruments are then tracked by the navigational system as the surgeon operates. The surgeon is able to see exactly where his instruments are in relation to the patient’s anatomy, even in minimally invasive procedures, where direct visualization is not possible.

These advances have led to significant developments in minimally invasive surgery but arealso being utilized in traditional surgical procedures as well. Increasing numbers of hospitals are obtaining this updated technology and more surgeons are being trained in the use of the equipment every day. As a result, these procedures are being recommended with greater frequency; however, this technology can carry a hefty price tag. The da Vinci robot has been estimated to cost almost $2 million, while some of the disposable surgical attachments can range from $3,000 to $6,000. Costs for stealth guided or computer assisted navigation systems can also range over a million dollars as well.

The increasing prevalence of these types of surgical procedures has led to robotic assisted and stealth guided surgeries finding their way into Medicare Set-Aside (MSA) Proposals. Surgical pricing in MSAs reviewed by CMS has always been inconsistent at best. Costs can vary dramatically for the same procedure, even within the same jurisdiction. Recently, we received a CMS approval that included a lumbar fusion procedure at a cost of $108,000.00, much higher than any previous lumbar fusion procedure seen within the same jurisdiction. The medical records indicated that a stealth guided lumbar surgery was simply under consideration.  While the additional CPT codes alone would not account for the inclusion and dramatic increase in the cost of the surgery, the fact that this technology is typically found only at tertiary facilities where facility costs tend to be much higher could also contribute to this increased cost as well.  As these types of procedures become more prevalent, it is likely that increased surgical costs will be seen in CMS approvals for MSAs where robotic assisted or stealth guided assisted surgical procedures are simply discussed.  As such, we recommend obtaining a thorough legal and medical analysis of your claim prior to submitting an MSA to CMS to evaluate the likelihood of inclusion of these types of surgeries.