Living with constant back pain can limit your mobility and take a toll on your daily quality of life. For those individuals with Medicare benefits who are suffering from back pain, you may be eligible for some or all coverage related to back pain treatments.
As with all medical insurance, the type of treatment and the amount of coverage depends on your personal situation, your doctor’s diagnosis and documentation of your individual condition, and the procedures approved by your individual Medicare plan. Even with Medicare benefits, there may be some costs not covered by your insurance plan that you will be responsible to pay.
Back Pain Treatments and Therapies with Medicare Coverage
The most typical back pain treatments covered by Medicare plans include cortisone injections, physical therapy, diagnostic lumbar medial branch blocks, therapeutic radiofrequency ablation, medications, chiropractic therapy, surgery, and acupuncture.
Surgery is generally a last resort for back pain and should only be a consideration after traditional treatments have failed to provide measurable relief. Medicare does pay for medically necessary back surgery based on a recommendation from your neurosurgeon or orthopedist.
Back pain treatments approved for coverage by Medicare may not pay for the full cost of the procedures. You may be subject to copayments, coinsurance, annual deductibles, and some out-of-pocket costs. Be sure to read your plan’s details related to the type of treatments your condition requires.
The number of treatment sessions or injections allowed annually within Medicare plans will depend on the level of pain management required for relief, how often treatment is needed for relief, and where the treatment or therapy is given. Some back pain treatments will require pre-certification before treatment can begin. Your physician will need to obtain the required prior approval from Medicare for those procedures.
• Medicare Part A covers back pain treatments needed by hospital inpatients.
• Medicare Part B covers outpatient treatments including physician diagnoses, injections, physical therapy, acupuncture, and occupational therapy.
• Medigap Plans help to cover those remaining costs of approved Medicare back pain treatment that is not fully funded by Medicare. Medigap plans are no longer available to new Medicare enrollees. If you are considering switching to a new plan, talk with your provider to determine if there is a better insurance plan available or if you should remain with your current plan.
• Medicare Part D covers doctor-prescribed medications.
• Medicare Advantage Plans differ from state to state on the type and number of treatments. While Medicare Advantage Plans provide a wider range of coverage than the basic Medicare Parts A and B, they must cover all of those procedures approved in the basic Medicare plan guidelines. Anyone with an advantage plan will need to consult with their insurance provider to learn what forms of back pain management are covered and at what cost.
Back Pain Treatments and Therapies Not Covered by Medicare
Even when your physician recommends a back pain treatment or therapy, it is not a guarantee that the procedure will be covered by Medicare. Here are some typical treatments that Medicare does not cover.
• Massage therapy is not a covered Medicare treatment.
• Image-guided lumbar stenosis decompression is not a covered Medicare treatment.
• Discectomy is an operational procedure to correct a herniated disc and is not covered by Medicare. The rationale is that herniated discs can be corrected with non-surgical treatments including physical therapy and pain medications.
• Artificial lumbar disc replacement surgery is not covered by Medicare. The rationale is that alternative treatments can treat this condition with physical therapy and pain medications.
• Piriformis Syndrome surgery is a procedure performed to correct sciatic nerve irritation caused by the piriformis muscles located in the buttocks. Medicare will generally not cover this surgery as the typical treatment for this condition is with massage therapy and anti-inflammatory medications.
Medicare plans can help with back pain treatments but, the type of coverage required for your personal condition will need a professional evaluation by a Medicare-approved physician and recommendation and may also need a pre-certification before treatment can begin. A review of the approved pain management treatments covered by the Medicare benefits within your insurance plan will help you better understand what procedures you get and what costs you may need to pay. You may want to consider switching to a more inclusive Medicare Advantage Plan that will help with prescription drugs and help to lower your out-of-pocket expenses. Compare the options available in your area to find the coverage that’s right for you.