Recovery from muscle relaxation after the use of neuromuscular blocking agents (NMBA) during surgery is crucial for patient safety [1]. Specifically, the importance of complete recovery from muscle relaxation has been emphasized owing to the occurrence of various complications resulting from residual muscle relaxation after surgery [2,3]. Compared to traditional reversal agents, sugammadex causes rapid recovery from muscle relaxation regardless of age or patient condition, garnering attention for its advantages such as reducing urinary or respiratory complications and enabling a quick return to daily activities [4]. In traffic accident patients who often present with severe conditions, such as multiple fractures or intra-abdominal bleeding, the appropriate use of NMBAs is necessary for surgery. Furthermore, adequate recovery from muscle relaxation is required to reduce postoperative complications, suggesting that sugammadex has several benefits. However, recently, there have been many cases in which sugammadex used for patients in traffic accidents has been deducted from claims in auto insurance evaluations, necessitating an analysis of this trend.

This study analyzed the characteristics of patients whose compensation claims were denied by the Auto Insurance Claims Review Department of the Korean Health Insurance Review and Assessment Service (HIRA). By conducting a retrospective single-center review, we aimed to identify common factors for claim denials among these patients and contribute to reducing the deduction rate of sugammadex claims.

Overall, 251 patients had deducted sugammadex payments from the Auto Insurance Claims Review Department of the study period (January 2019 and December 2023).

We observed a significant reduction in the sugammadex deduction rate in 2023, dropping from an average of 88-100% in previous years to 43.4% (Table 1). However, despite these improvements, deductions persist (Fig. 1).

Table 2 displays the patient demographic data. The American Society of Anesthesiologists physical status class distribution indicated that ~40% of the patients were American Society of Anesthesiologists class 3 or higher. There were 80 patients aged ≥ 70, accounting for 31.9% of the total. Approximately 80% of the patients had various comorbidities. Emergency surgery accounted for 53 cases (21.1%), and 15 cases (6.0%) involved massive bleeding. Extubation was not performed after surgery in 24 cases (9.7%).

Orthopedic surgery accounted for the highest number of cases (57.8%), followed by neurosurgery, plastic surgery, and other specialties, as detailed in Fig. 1. As shown in Fig. 2, sugammadex was primarily used for deep blockade (55.1%), high-risk assessments (23.1%), and respiratory failure or desaturation (12.2%) during emergence for other reasons, including morbid obesity, poor vital signs, and short duration of surgery.

In this study, we evaluated the characteristics of patients whose sugammadex claims were denied by the Auto Insurance Claims Review Department of the HIRA. The results of this study highlight the discordance between modern clinical guidelines and the policies of the Auto Insurance Claims Review Department of the HIRA. This discordance underscores the need for policy revisions to align insurance practices with the current clinical guidelines to ensure patient safety and optimal outcomes.

According to the drug approval conditions for sugammadex by the Korean Ministry of Food and Drug Safety (MFDS), it can be used for the reversal of NMB induced by rocuronium or vecuronium, with no particular contraindications aside from precautions [7]. Sugammadex is not used when the conventional reversal agent fails to restore recovery of NMB but is used for the reversal of NMB induced by rocuronium or vecuronium in itself [4,7]. Therefore, the administration of sugammadex for the recovery of NMB in traffic accident patients is an appropriate use of the proper drug approved by the Korean MFDS based on standard indications.

However, the findings of this study reveal that the Auto Insurance Claims Review Department of HIRA has substantiated deductions for sugammadex payments despite adequate usage based on clinical indications. Persistent deductions may discourage physicians from using sugammadex, thereby restricting their autonomy in prescribing the necessary medications and their ability to provide optimal care, which may be an ethical issue. Hopefully, the percentage of deducted claims has dropped significantly to 43.4% by 2023. We believe that this change indicates improved documentation practices or policy shifts. Initially, 58.2% of cases had poor or very poor documentation of NMT results before administration reversal agents until 2020, likely contributed to the high rate of claim deductions, especially in 2019. However, from 2021 onwards, all anesthesia records consistently included NMT results before administration reversal agents, with documentation quality improving to between 75.5% and 97.2%.

Nevertheless, despite improvements in record accuracy and detailed justifications for sugammadex use, sugammadex payment deductions persist, indicating that better documentation alone does not resolve the underlying issue of claim denial. According to the informally known criteria for the use of sugammadex in traffic accident patients by the Auto Insurance Claims Review Department of HIRA, sugammadex payments are not deducted in high-risk patients aged ≥ 70 years, with an American Society of Anesthesiologists physical status class of 3 or higher, or the status of a deep NMB of PTC 1-2, with mandatory documentation of NMT monitoring. However, payments for the use of sugammadex in high-risk elderly patients who were evaluated as American Society of Anesthesiologists physical status class 3 and had a high risk of postoperative pulmonary complications, such as atelectasis and pneumonia, have been deducted in quite a few cases. According to Table 2, 80 elderly patients (31.9%) have had deducted sugammadex payments in auto insurance evaluations, despite intraoperative NMT monitoring in all patients. Moreover, out of 251 patients, 90 (35.9%) were classified as American Society of Anesthesiologists physical status class 3, indicating a high-risk status with significant comorbidities; these patients are more likely to experience complications and require precise management of MNB and its reversal. Despite the high clinical need, many sugammadex payment claims have been deducted. The persistently high deduction rates, especially in patients with American Society of Anesthesiologists physical status class 3 or higher, suggest a misalignment between the clinical guidelines and the Auto Insurance Claims Review Department of the HIRA's deduction policies.

The new 2023 guidelines for the antagonism of NMB emphasize the critical importance of selecting an appropriate reversal agent based on the NMB level at the end of surgery [6,8]. These updated guidelines from both the American Society of Anesthesiologists and European Society of Anesthesiology and Intensive Care (ESAIC) provide clear recommendations to ensure patient safety and optimal recovery. The guidelines strongly recommend sugammadex for patients in a deep NMB (TOFc of 0 or PTC ≤ 1) due to its rapid and reliable reversal of profound NMB for ensuring patient safety and preventing complications such as respiratory depression or arrest. In cases of moderate NMB (TOFc 1-3) cases, sugammadex remains the preferred agent, providing quicker and more complete recovery than conventional agents. For shallow blockade (TOFc 4 and TOF ratio < 0.4), sugammadex is recommended because of its efficacy in achieving complete recovery. When minimal blockade is present (TOF ratio ≥ 0.4), sugammadex is preferred, but neostigmine can be a reasonable alternative if quantitative monitoring confirms adequate spontaneous recovery. However, the choice should be guided by the patient's risk factors and overall clinical condition. The guidelines highlight that inappropriate use of neostigmine in deep blockade states can lead to incomplete reversal and residual neuromuscular blockade, increasing the risk of postoperative complications. Conversely, sugammadex is recommended owing to its ability to safely and effectively reverse deep NMB, particularly in high-risk patients and those with significant comorbidities.

In the analysis of the patterns of NMB in this study, 67.1% of deducted cases exhibited deep and moderate NMB, which required sugammadex, according to the recent NMT monitoring guidelines. Moreover, the average TOFr in cases showing TOFc 4 was 36.7%, representing shallow NMB requires sugammadex for the reversal from NMB. In addition, insufficient recovery from NMB after administration the first reversal agent was seen as shallow blockade status, with a mean TOFr of 37.6%. According to recent guidelines, all cases require the use of sugammadex for NMB reversal. Despite the clear clinical indications for sugammadex, the Auto Insurance Claims Review Department of the HIRA deducted these claims, which contradict established guidelines and may compromise patient safety and quality of care.

Patients undergoing short surgery or additional NMB encounter deep NMB at the end of surgery. In short surgeries, such as closed reduction of nasal bone fractures, it generally takes approximately an hour after administering rocuronium for intubation for sufficient recovery to use conventional reversal agents such as neostigmine or pyridostigmine [9]. Similarly, additional administration of NMBA before the end of surgery may cause a deep NMB state at the end of surgery. As inadequate recovery from NMB due to the inappropriate use of conventional reversal agents in deep or moderate NMB increases the risk of respiratory depression and respiratory arrest, it is necessary to wait until the patient reaches a minimal block state for the use of conventional reversal agents. In such cases, conventional neuromuscular reversal agents should not be used and sugammadex should be administered instead [10]. The NMT profile analysis in the present study supports these findings. Most patients exhibited deep NMB within 30 min of NMBA administration, which transitioned to deep or moderate blockade within 30-60 min, shallow blockade within 60-120 min, or minimal blockade beyond 120 min. These results emphasize the importance of selecting an appropriate reversal agent based on the NMB state at the end of surgery, considering the time since the last NMBA administration.

The 2023 American Society of Anesthesiologists and ESAIC guidelines advise that neostigmine or pyridostigmine should only be used once the TOF ratio exceeds 0.2-0.4 [6,8]. Waiting for the minimal block state requires the maintenance of unnecessary anesthesia and endotracheal tube intubation, even if the patient regains consciousness, leading to extended anesthesia time, increased patient discomfort, and potential additional complications, posing significant risks to patient safety. As both recent guidelines recommend using sugammadex if the TOF ratio has not reached 0.2-0.4, it is crucial to ensure that recent recommendations are followed and not to restrict the use of sugammadex.

This study had some limitations. First, the study was conducted at a single center, which may have limited the generalizability of the findings. These results may not fully represent the status of sugammadex payment deductions at other institutions with different patient populations, clinical practices, and administrative policies. Replicating this study in multiple centers with diverse patient populations is necessary to confirm our findings and enhance their applicability. Second, although there were improvements in documentation quality over the study period, poor documentation of the NMT results could have influenced them. Third, this study did not provide long-term follow-up data on patient outcomes after administration of reversal agents. Consequently, the effects of sugammadex versus those of conventional agents on long-term patient safety and recovery remain unclear. Fourth, although this study highlights the issue of sugammadex payment deductions, it does not extensively explore their economic implications on overall healthcare costs, patient outcomes, and institutional practices.

In conclusion, this study analyzed the status of sugammadex payment deductions in patients with traffic accidents. However, insurance deductions by the Auto Insurance Claims Review Department of the HIRA remain high, despite the clinical necessity of sugammadex, especially in cases of deep and moderate NMB. Ensuring thorough documentation, particularly NMT monitoring, may help to reduce these deductions. The choice of reversal agent should be guided by the best clinical evidence rather than economic considerations to ensure optimal patient outcomes. Ensuring adherence to these guidelines helps to protect patient safety, optimize recovery, and maintain the highest standards of medical care. Continued collaboration between health care providers and policymakers can help achieve more consistent practices. Further research and discussion are needed to refine these policies and ensure that they provide the best care for patients.