Original Medicare will cover pain management services when medically necessary. Yet, some services or treatments may require payment based on your specific situation.
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Additionally, costs for some pain management services may vary based on your diagnosis. It is important to find a pain management doctor near you that accept Medicare.
Below, we review Medicare coverage for pain management, when it is covered, and how to find a doctor in your area that accepts Medicare.
Medicare Coverage for Pain Management Treatment Options
Medicare coverage for pain management looks different depending on the circumstances and method of treatment. In certain situations, Medicare will cover treatment options that may not receive coverage under other circumstances.
Medicare only covers pain management when medically necessary for your specific condition.
Pain management treatment options may include:
- Physical Therapy
- Chiropractic Treatments
- Medications
- Injection Based Treatments
- Surgical Intervention
While some individuals may require surgery for pain management, others consider it a last resort. There’s no guarantee that surgery will provide pain relief. Unless an orthopedic or neurosurgeon can guarantee over 50% improvement, it is recommended to defer surgery in favor of alternate routes of pain relief.
If your physician deems pain management treatment, you will be responsible for the applicable Medicare copayment, coinsurance, and deductible(s). If you undergo outpatient treatment, you may need to meet the Medicare Part B deductible, then cover the 20% coinsurance.
If you are hospitalized for your treatments, you must cover the Medicare Part A deductible and any applicable coinsurance for your visit.
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Additionally, a Medicare Part C (Medicare Advantage) or a Medicare Supplement (Medigap) plan will cover pain management per the policy’s guidelines. If Original Medicare covers your treatment, you should receive coverage from your Medicare Advantage or Medicare Supplement plan.
Medicare Supplement plans pick up the coinsurance for which you are responsible with Original Medicare only. However, your Medicare Advantage plan may require you to receive a referral to see a pain management specialist.
If you require medication to treat your condition, your Medicare Part D plan or Medicare Advantage Prescription Drug Plan (MAPD) will be responsible for covering your medication. You will want to ensure your plan’s formulary covers the drug before picking it up at your pharmacy.
Medicare Coverage Guidelines for Lower Back Pain Management Injections
Per the standard Medicare guidelines, cortisone injections for lower back pain usually receive coverage without prior authorization through Medicare Part B. However, different doses have different costs. So, make sure to ask your doctor about the allowable amount for each procedure.
Regardless of the cost of your injection, you may be responsible for the Medicare Part B deductible, then 20% of the remaining cost.
Coverage through Medicare Supplement plans is crucial for those with lower back pain management needs. When undergoing pain management treatments, supplemental insurance protects you financially.
When you enroll in a Medicare Supplement plan, you will likely receive coverage for the Medicare Part B 20% coinsurance. Depending on the Medigap plan you choose, you also may not be responsible for copayments.
There are many different types of injections for treatment available to those with either chronic or acute conditions. We’ll acquaint you with some of the most common examples below.
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How Much Does Radiofrequency Ablation Cost With Medicare?
Radiofrequency ablation is also known as RFA or rhizotomy. It is a minimally invasive procedure using heat to stop nerve fibers from carrying pain signals to the brain. The non-surgical procedure results in immediate, long-lasting pain relief.
When a doctor deems RFA medically necessary, Medicare covers it. However, to be deemed medically necessary, your pain must be extreme, and receive no relief with alternative pain management solutions.
To determine this, you may need to prove that other methods weren’t successful in managing your pain. You could be responsible for a copayment, deductible, or coinsurance. Costs may vary on Medicare Advantage plans, so contact your carrier for details.
Does Medicare Cover Epidural Steroid Injections in 2023?
Epidural steroid injections are minimally invasive and long-lasting pain relief treatments. During this procedure, your doctor injects a corticosteroid and an anesthetic numbing agent into the spine. You must meet specific requirements for Medicare coverage to begin.
Like with other injections, you will have to prove that alternative treatments were unsuccessful before Medicare will cover an epidural injection.
If your doctor stated this treatment is medically necessary after failed attempts to relieve your pain, Medicare Part B will cover its portion of this treatment.
Is Spinal Decompression Covered by Medicare?
Medicare does not consider certain spinal decompression therapies as a medically necessary service, even if they provide relief to your pain. However, in rare circumstances, you may receive Medicare coverage for spinal decompression.
Often, if you receive spinal decompression or any other chiropractic service, you will be responsible for paying out-of-pocket unless your physician deems it medically necessary. However, due to the short-term relief, this treatment is rarely medically necessary.
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Under the rare circumstance spinal decompression is medically necessary for your condition, you will receive the standard Medicare Part B coverage.
FAQs
How to Find Medicare Coverage for Lower Back Pain Management
To receive successful pain management treatment, you must find a physician skilled in this specialty. Once you find a physician who accepts Medicare, you will want ensure you are on the right Medicare plan to cover your out-of-pocket responsibilities.
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Hi Jagger –
Will Medicare pay for ablation of both left and right SI joint done duringthe same procedure?
Hi Victor, if both of procedures are deemed medically necessary, Medicare should cover both procedures on the same claim. Please contact Medicare directly to confirm as this will be a case by case basis.
I currently on Medicare and have a Medigap supplement plan F. I have been receiving pain management infusion therapy for several months. The facility is now billing me for all of these infusions. When I called them, they told me that Medicare hasn’t covered this service with their pharmacy since 2013. Is this correct and if so, does that mean I am responsible for these charges? Do you think I could appeal this with Medicare?
Karen, if the facility you are receiving the injections from does not accept Medicare or if Medicare does not cover your treatment, you will be responsible for 100% of the costs. To verify that Medicare does or does not cover a specific injection, you will need to contact Medicare directly.
They (your insurance carrier) are responsible to pre authorize your treatments. As we are also responsible to keep track of any changes reguarding our coverage. Your doctor’s office must not have gotten pre authorization? It’s their job to do so..before hand.
If I signed an ABN for Anesthesia provider for providing anesthesia during an image guided epidural, is the provider required to file Medicare? What changed in the coverage for this service?
Cathy, when you sign an ABN you are given three options. Option 1 requires the doctor to bill Medicare, however Medicare is not required to pay. If they do not pay, you will be required to cover the costs. Option 2 states that you will cover the costs and the doctor is not required to bill Medicare. Lastly, option 3 states that you do not want to have the procedure performed. So, the answer to your question lies in which of the three options you chose when signing the ABN.
I have been told medicare no
Longer cover the anesthesia for lumbar injections as of Dec 2021
Is this true
Sharon, Medicare did make a change to their rules surrounding coverage of Anesthesia for lumbar injections. However, it is best to speak with your doctor to for the most updated information.
Hello:
I am a disabled senior, age 69 years old.
My doctor has written a letter to Medicare for a prescription for a
ThevoRelief Pressure Relief mattress. It is listed as the best pressure reducing mattress on a list of top 5 mattresses for
Medicare. But the 2 companies in the United States tell me they
do not work directly with Medicare.
Where can I get help to pay for this $2,000. mattress I need for
my spine problems that surgeons tell me it is too risky to operate
on and surgery will make me worse.
I need this mattress.
What can I do?
Is it true that Medicare & a supplemental plan won’t approve an MRI for sciatic pain without first going thru 6 weeks of physical therapy? Pain management doctor will not see patients without an MRI first and internist won’t proscribe MRI without therapy first.
Hi Pam! I have not heard of this before, but it could be something that is determined on a case-by-case scenario. Your best option is to contact Medicare directly with your doctor on the line with you to find out. That will prevent you from going back and forth between your doctor and Medicare.
My sister is on medicare. She is disabled. She also has a supplemental policy. She requires back surgery to put cages in for vertebrae. They told her she has to go through certain steps before she has surgery like pain management, steroid injections. She has had several injections. She is in so much discomfort. She can’t sleep in bed, she has pain with position change. She can’t hardly walk. She is so depressed, cries. They keep telling her she has to go through these steps first. That this is Medicare rules. First Is this true? To me this is abuse. She is miserable. Now it’s two weeks before she goes back. Is this Medicare’s protocol?
Hi Carmen! Unfortunately yes, Medicare does require you to try alternative treatments before they approve some surgeries. I would get her doctor and Medicare on the phone at the same time to see if there are any other options to fast-track her surgery getting approved.
I have cervicle and lumbar facet arthropathy at multiple levels. My question is, how often Medicare part B pays for multiple level bilateral facet injections? Also what do I need to do to make sure it’s actually paid. I have had MRI’s of both areas and have been in pain for more than 2 years. My pain management Doctor suggested these procedures instead of jumping to surgery. Please help. Thank you. Sandra
Hi Sandra! Do you currently have Part B or a Medicare Advantage plan? If you have Part B, you can find information to help answer this question here. If you have Medicare Advantage, you would need to ask your carrier directly since the summary of benefits is different per carrier.
Hello Ms. Engle; My wife has been receiving pain management injections for over 4 yrs, They have been a great help to her, by being able to go oxycodone to tramadol, but now the hospital is requiring her to see a nurse practitioner before she can get her next injection saying that Medicare reuires this additional visit, I am wondering if this is true or just something the hospital is doing to get more money out of Medicare patients.
Hi Douglas! I would need to know what parts of Medicare your wife has, as well as when she saw her doctor last. Normally, she would need to be seen one time per year to continue injections. However, there could be other factors that come into play. If she has Medicare Advantage, they may have changed the guidelines for that injection depending on the carrier she is enrolled with. It’s hard to answer your question without knowing more details.
My wife only has Part A and Part B plain jane Medicare. She receives a shot every three months from a pain management clinic, Her last shot was now some 5 months ago, because she feels as though she is being taken for a ride with having to pay for these additional visits.
Medicare has been making many changes recently to both the prior authorization list as well as requirements around pain management treatments. I do not think your wife is being taken for a ride. It’s most likely due to Medicare having stricter guidelines that now require a treatment plan to be sent over annually to have the injections approved.
They are not doing it annually, They are doing it one month after every visit.
I would reach out to Medicare directly and explain the situation. They will be able to determine if and why these monthly visits are necessary. It could be something as simple as the wrong CPT code being put in by the billing department.
I’m currently on MediGap/Supplement G. Premium is $180mth. I’m considering switch to a Medicare Advantage plan hoping to save some $ off the premium of my G plan. I have an in dwelling, Medtronic pain pump (opioid medication). I’ve had this pain pump for about 5yrs now and have never had a billing problem, ever (I’ve had Medicare Advantage plans in the past and this is my 1st year with G). I receive my opioid medication refill every 6 weeks. Recently in researching the Medicare Advantage plans, an Insurance Advocate has indicated that the Insurance carriers/Advantage Plans are now treating the “refills” as DME treatment and thus implying the theory “20% of the Medicare-approved amount, and the part B deductible applies”. This could pose a tremendous bill owed if so. In previous years my claims with my former Advantage plans always paid accordingly, not imposing the DME 20% reimbursement. What is the true rule of thumb ? Is the REFILLING of opioid medication into my internal pain pump considered a DME classification ?
Hi Dinah. Thank you for your question! Yes, your opioid medicare refill for your internal pain pump is classified as DME. DME supply drugs are drugs that require administration by the use of a piece of covered DME (e.g., a nebulizer, external or implantable pump). The statute does not explicitly cover DME drugs; they are covered as a supply necessary for the DME to perform its function. A category of drugs Medicare covers as a DME supply are drugs for which administration with an infusion pump in the home is medically necessary. From what I can find, this change was implemented in 2016. The insurance advocate you spoke to is correct. If you change to a Medicare Advantage plan, you may save money in monthly premiums. However, you’ll pay out of pocket costs in the forms of coinsurance and deductibles that you would not have had to pay with Plan G. The only cost you’re responsible for outside the premium you pay for Plan G is the Part B deductible. You have very good coverage now, given your current health requirements, I do not feel switching to a Medicare Advantage plan will put you in a better financial position. I hope this helps!
Hi Doll. Each Advantage plan has there own summary of benefits. You would need to pay real close attention to how many times they will cover the injections and how much you will pay out of pocket each time you get one. I would also clarify with them that you need sedation when you go to make sure they will cover it. It’s also possible that your doctors are not in the network of the plan. The coverage is very different then your current Plan N. The Advantage carrier chooses how much of the service they will cover, it’s not standardized like your Plan N. You may save money in monthly premiums, but you will spend more out of pocket in the forms of copays and coinsurance. It’s very possible that you may spend more out of pocket annually with your Advantage plan than you would with Plan N since you go to the doctors regularly. I would seek the help of an agent before you make this change.
Hi, I suffered a compression fracture in my L4 vertabre last year, caused by multiple myeloma. Back pain was severe enough to warrant a kyphoplasty in January. It had some possitiveveffect, but since then, the pain has Moved further down my back. My oncologist and I are discussing spinal facet injections. It’s my understanding that Medicare Part B covers the procedure, assuming a lengthy list of prerequisites is met. It would still leave a sizable co-pay. I purchased a Medicare Part G plan his year. Would it pick up some or all of the co-pay?
Hi Roderick! When you have Medicare with a Medigap plan, you don’t have to ever worry about copays. If you have Plan G, the only out of pocket cost outside the monthly premium you’ll have to pay is the Part B deductible. Your Plan G will cover any coinsurance leftover after Part B pays its portion of your spinal facet injections once you’ve met the Part B deductible. I hope this helps!
If I have had the maximum number of Back Injections, Can my doctor bill me the Medicare Allowed amountt if I choose to have more injections?Does the injections count start January to January?
Hi Donna! Your doctor will bill Medicare first. If they deny the claim due to the number of injections being maxed out for the calendar year, then the remainder will be billed to you. Yes, the injections would be from January to January. Let me know if you have anymore questions!
Hello! I’ve been in severe pain since 2002 and had lower back surgery (L4-S1). In addition, I need multiple injections throughout the year, along with medications. Last year Medicare starting limiting the dosage of medications I’ve taken for years! Now they’re limiting the injections per year which is really causing me more pain. I normally have 8-12 ESI, facet blocks, and trigger points throughout the year. Now Medicare has decided to limit my injections to 6 a year. The issue with that is they count the total number of injections, regardless if they’re for my low back or neck (which I started getting treatment on the neck about 5 years ago). Now I’m hurting more and spending abundantly more time in bed than working the affected areas with therapy at home! The pain is real and it’s taken more of a toll on me due to these restrictions! Is there an appeal process with Medicare, if so, is it worth it to try and call them? Like some, I’m on SSDI as well, and have not reached 65! This is very frustrating to pay premiums for the insurance, then only get limited treatment! Please, can you offer any advice on how to approach this with Medicare? I’m not sure if I talk with Medicare, or if my doctor has a better chance on an appellate process, if any! Thank you for all of the insight you’ve given through the years, along with all the articles you’ve written, and last but not least, the time you’ve taken out of your busy schedule to personally respond to those of us needing guidance!
Hi Larry! Thank you so much for all the wonderful feedback! I’m so happy to hear we’ve helped you during your Medicare journey. There is an appeal process that we have outlined here. Make sure you have your Medicare Summary Notice, which comes in the mail about every three months. I would call your doctor ahead of time to let them know you plan on appealing this. That way, they can provide you with any additional documentation you need. If you have a supplement policy through us, our Client Care Team will be able to help you with the appeal as well! I hope this helps. Let me know if you have any more questions.
Would DRS Protocol for lower back and neck pain, by a Chiropractor be covered by Medicare? I also have United Health Care, Medicare Advantage and live in central Florida.
I get Radio Frequency Ablation procedures done about once a year. Will Medicare cover the anesthesia?
I had an MRI of my lumbar that showed Spinal Stenosis with fracture. I had epidural injection. Will this be covered by Medicare. My supplemental is Aetna.
Hi Anita! Yes, Aetna considers epidural injections medically necessary for the treatment of back pain and should be covered. You can find more detailed information here.
I am currently getting the steroid cortisone shot and have been for the past two yesrs. My question how frequently can I get the injection I do get amazing relief but after my last shot i am ready for another. It’s bern 3 months Usually I can go 5 to 6 months for the next shot but for some reason my activity my back pain was getting worse is there a time limit month wise or hit him many times a year I can get there and have it approved by Medicare
I have a medicare advantage plan and need these injections. Do you know how many per year are allowed by medicare for spine and also non spinal joints?
My brother had several spinal injections for back pain and he has Medicare and Anthem BlueCross Blue Sheild. They told him only two injections given by his orthopedic surgeon were covered. Why only two when according to his MRI he has problems in his Thoracic area and Lumbar area and sacral area as well.
Hi Flo! This is something I would recommend you call Medicare directly to ask. They MAY be able to help you find a way to get two injections approved per area.
These conversations have been very helpful, Thank you! My other alternative would be a wheelchair.
So happy to hear we were able to provide some guidance for you!
I am in pain management now for lower back pain and hernia disk I have taken other meds and therapies but pain is now severe I am now pay ing for my doctors appointments by cash does medicare not pay for any of this medicare is paying and my co pay for part of my meds I would appreciate a better understanding on why I am paying for all of tbis
Hi Pat! Part B covers doctors’ visits and other outpatient services. Part D would cover your prescription medications. If you only have Part B & no Medigap plan, then you would be responsible for the Part B deductible + 20% of the costs of your doctors’ visits.
Hello, I’m currently receiving facet joint injections and nerve blocks. I’ve been informed this may be the case for a while. I’m on SSDI, and per their rules I must be transitioned to Medicare by my 25th month, which will be early 2020. Can I get Medigap even if I’m not 65? These treatments are expensive. Thanks for your help!
Hi Dorothy! The answer is dependent on what state you live in. If your state offers Medigap plans to those on SSDI, then yes, you can purchase a Medigap plan if you’re under 65. However, the premiums are usually very high. If you’re unable to afford the higher premiums, you’ll get a second Open Enrollment Period when you do turn 65 to enroll in a Medigap plan with Guaranteed Issue. It looks like you may be in California, if so, then there are Medigap plans offered to those on SSDI. I hope this information helps!
My medicare advantage plan is telling my pain management doctor that I must have 2 epidural injection “tests” before I can have a radiofrequency ablation approved. The plan claims that Medicare requires this. Does Medicare actually require these 2 “tests” before radiofrequency ablation is approved or is it just my Medicare Advantage plan’s rule to discourage a patient going through all of the process to get a radiofrequency ablation?
Hi Reginald! Medicare Advantage plans do have their own limitations & restrictions. It is possible they may require additional tests to be done before they approve medical treatment. However, Medicare could require these tests to be done. Without knowing your carrier, doctor and/or type of advantage plan, it’s impossible for us to know. I would give Medicare a call to see if these tests are required by them. If not, then it could be your plan or even your doctor that’s making it a requirement vs Medicare. Ask your doctor what the CPT codes are & have those on hand when you call Medicare.
My Dr. said I have sciatica and some arthritis after viewing my Mir and that I need to see an orthopedic/neurologist Dr. About surgery. Am I covered?
Hi Lynne! Assuming you have Original Medicare, your Part B will cover 80% of your medical costs at the orthopedic/neurologist. If you have a Medicare Supplement Plan, the remaining 20% will also be covered. If you have Plan F or Plan C, your Part B deductible will also be covered. If you don’t have a Medicare Supplement Plan, you’ll be responsible for the remaining 20% Medicare doesn’t cover, as well as the Part B deductible.
hello. i read above that medicare doesn’t cover ultrasound guided lumber epidural steroid injections. the ultrasound guidance is considered nationally the standard of care with these injections per the pain management anesthesiologists performing the injections. i have been getting them for some time + with this guidance. i will be medicare in the not too distant future. currently i have anthem blue cross + they cover the injections, ultrasound + IV sedation required with authorization. the auth folk with my blue cross said once i hit medicare they won’t do the authorization process anymore but if medicare doesn’t cover ultrasound guided injections, what am i to do? thank you.
Hi Linda! It sounds like Blue Cross won’t do the authorization process since you will be on Medicare. Once you’re on Medicare, they will be the ones doing the authorization process. You will then need to pick up a supplemental Medigap plan to cover what Medicare leaves up to you to pay, which is 20% under Part B. I would talk to the doctor that's giving you these injections and ask him/her what the billing code is and if Medicare will pay for them since they're considered medically necessary. They will be able to look these injections up to see if Medicare will pay for them.
How many RF Is covered for each side I mean can I have RF BILATERAL twice
Hi Sylvia! Your best option would be to ask your doctor. They will know how many times they can bill Medicare for this service per your situation and what’s considered medically necessary.
I have an ESI in Oct 2018, Nov. 2018, March 2019, June 2019, and now again in Sept 2019. They are effective but only last 3 or 4 months. I have been told no more than 6/yr. with Medicare. Would my year go from Oct. to Oct. or is it from Jan. to Jan? Confused?
Hi Mary! The Medicare calendar year resets on January 1st of each year.
I have had Rhizodomy done on my lower back several times. This year I needed to get one done within the 6 month period. My Dr. claimed that Medicare will not pay for the procedure before the 6 month period is done. How can I get Medicare to pay for the Rhizodomy sooner than 6 months. Is there an appeal process for this?
Hi. I can only get an epidural shot in my back if I get anesthesia. Does Medicare cover that? Thank you.
Hi Debbie! Yes, Medicare will cover anesthesia if it’s found to be medically necessary and administered by a provider who accepts Medicare Assignment. Your Part B deductible will apply unless you have a Medigap Plan that covers the deductible.
Hi Marvin! There is no limit on how many injections you can get as long as they are considered medically necessary. I would recommend contacting you Medicare Advantage carrier to confirm.
Hi Georgia! There is no limit on the number of injections a patient can get as long as they are considered “medically necessary.”
Hi Poppy! Yes, as long as it’s considered medically necessary, Medicare will cover the anesthesia.
Hi Robert! As long as it’s considered medically necessary, your Medicare Advantage plan should cover it. I would recommend contacting UnitedHealthcare to confirm.