ORIGINAL MEDICARE
Medicare coverage for lower back pain management is available when necessary. Although, some out of pocket costs could be your responsibility.
By the time most people enter the age of Medicare coverage, they’ve had some lumbar pain.
Recipients feeling lower back pain need to know what treatments and pain management therapies are proper.
The cause of the back pain determines a patient’s eligibility for treatments and pain management therapies.
There are many treatment options, including:
- Physical Therapy
- Chiropractic Treatments
- Medications
- Injection Based Treatments
- Surgical Intervention
Standard Conditions of Lower Back Pain Requiring Pain Management
Medicare coverage for lower back pain management helps with just one type of pain issue. When you go with a Medigap plan to help cover the out of pocket costs, you save money.
Sciatica
Only those feeling pain starting from the Sacroiliac joint, or SIJ, have true Sciatica.
The SIJ joint connects your hip to your spine. When the SIJ becomes inflamed from irritation or Arthritis, it causes Sciatic pain.
Disc Herniation
The outer portion of the vertebral disc contains the cushioning between the vertebral bodies of the spine.
A tear on the outer portion of the vertebral disc is disc herniation.
This tear causes the inside, or the nucleus, to extrude through its fibers at a certain level, although this condition can replicate Sciatic pain.
Lumbar Stenosis
Well, Lumbar Stenosis is in the category of Arthritis. It could also be the narrowing of the spaces within the spine.
This condition affects the surrounding nerves, which then, in turn, can also replicate Sciatic pain.
Facet Joint Arthropathy
The Facets are the joints extending from the spine that provide support and allow movement. Facet Joint Arthropathy refers to the degenerative disease that breaks down the cartilage around these joints.
Other standard terms for Facet Joint Arthropathy is Facet Joint Arthrosis or Facet Joint Osteoarthritis.
Lumbar Spondylolisthesis
Lumbar Spondylolisthesis is the movement or slipping of the vertebral body. This condition causes both pains and squeezing of the nerve, which can also mimic Sciatic pain.
Interventional Pain Management for Lower Back Pain
Interventional Pain Management is to proceed with conservative treatments vs. surgical invention. However, managing the symptoms can help to avoid more invasive treatment plans.
There are two types of pain management doctors:
- Non-interventional: those willing to mask the pain with strong opioid pain medications
- Interventional: those whose sole purpose is to help patients relieve their pain beyond medicine
Why Avoid Surgical Intervention
While some individuals may require surgery, others consider it a last resort. There’s no guarantee that surgery will provide pain relief.
Unless an Orthopedic or Neurosurgeon can guarantee you over 50% improvement, you want to avoid surgery at all costs.
Additionally, any surgery with the lumbar spine includes the risk of complications. You want to consider surgery as a very last resort.
Meaning you have tried and failed all traditional treatments, including Interventional Pain Management.
Medicare Coverage Guidelines for Lower Back Pain Management Injections
Per the standard Medicare guidelines, cortisone injections without needing prior authorization usually have coverage. Also, different doses have different costs.
Make sure to ask your doctor the allowable amount is for each procedure.
However, Medicare only covers 80% of approved medical services. You pay 20% of the cost. Also, you spend out of pocket on deductibles, coinsurance, and copayments.
Supplement coverage is crucial for those with lower back pain management needs. Undergoing Interventional or Non-Interventional Pain Management treatments, Medicare Supplement insurance protects you financially.
There are many different types of injections for treatment for those with either chronic or acute conditions.
Types of Pain Management Injections
Cortisone is a robust synthetic anti-inflammatory that goes in an area of the body
- SIJ Injections: These are therapeutic injections where cortisone goes directly into the joint through the needle.
- Lumbar Facet Injections: These are therapeutic injections where cortisone goes directly into the joints from a needle.
- Lumbar Medial Branch Blocks: Diagnostic procedure in which Lidocaine “tests” the joints nerve endings verifying one responds with pain relief. Doctors hit the correct nerve when the patient feels relief, making them a candidate for a Radiofrequency Ablation.
- Radiofrequency Ablation or RFA: Therapeutic procedure where nerve findings come from the Medial Branch Blocks (or MBB’s); these nerves then receive cauterization for long-lasting relief.
- Lumbar Epidural Steroid Injection: Therapeutic injection where cortisone goes around the hurt disc and nerve endings for pain relief.
Does Medicare Cover Radiofrequency Ablation
When a procedure is medically necessary because a doctor said it’s essential, Medicare will likely cover the treatment. You may need to prove that other methods weren’t successful in getting coverage for this treatment.
You may be responsible for a copayment, deductible, or coinsurance. Also, advantage plan recipients will have different costs.
How do Cortisone Steroid Injections Help with Lower Back Pain
Cortisone is a potent synthetic anti-inflammatory that goes into a specific area of the body.
Also, It helps reduce inflammation, which in turn helps to decrease pain.
For more help on how to beat back pain, you can check out 53 Health & Fitness Experts Tips, where 53 experts, including us, share top tips.
How Many Cortisone Shots Will Medicare Cover
Cortisone shots can help treat inflammation. Although, if a cortisone injection doesn’t help a problem for a sustainable period, it likely won’t be effective at all.
Repeat injections could cause damage to the body over time. Most orthopedic surgeons suggest no more than three cortisone shots annually.
Does Medicare Cover Epidural Steroid Injections
If something is medically necessary, Medicare will usually cover it at 80%. However, some requirements must be met for the coverage to begin.
Such as the reason for pain and details of failing to get relief from other treatments. If the pain isn’t sciatica or radicular pain, the injections are less useful.
Those in need of Medicare coverage for lower back pain management may qualify for an injection.
How Many Epidurals Does Medicare Allow in a Year
Medicare has specific requirements for Epidural Steroid Injections (ESI). However, the injections must be medically necessary to relieve pain.
Six or more weeks of conservative therapy need to fail, and the patient must complete physical therapy. Also, the Patient must complete systemic analgesics, muscle relaxants, and activity modification.
An MRI or CT image study needs to be done to confirm no tumor or another space-occupying lesion is the cause of pain. A physical exam should prove regular radicular pain.
The patient can’t have non-specific lower back pain or failed back syndrome.
No more than two levels of injections can occur during the same session for transforaminal epidural injections. Also, ESI with ultrasound guidance won’t have coverage.
The requirements for continuing epidural injections as well as facet joint injections are different.
Does Medicare Cover Facet Joint Injections
The procedure must be medically necessary for back or neck pain when facet joint syndrome could be suspected.
The request should be for one or more of the following:
- Diagnostic facet injections
- Therapeutic or repeat doses
- Trigger point injections
- Sacroiliac joint injections
- Repeat Sacroiliac injections
For each, you must meet specific criteria.
Does Medicare Cover Physical Therapy for Back Pain
Medicare may cover physical therapy, depending on where you get your services.
Part B will generally pay for your physical therapy services if received in an outpatient setting. However, it only covers 80%, so you’ll need a Medigap plan to get the remaining 20% covered.
Get Medicare Help with Lower Back Pain Management Coverage
The benefits of a Medicare Supplement/Medigap plan varies, depending on which letter plan you choose. Also, you can compare the top two Medigap plans, Plan F vs. Plan G.
We can help guide you to find the best plan possible for all your individual needs. Click or call today, our agents are here to help, and our services are 100% free.
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.
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.
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.
Hi Robert! As long as it’s considered medically necessary, your Medicare Advantage plan should cover it. I would recommend contacting UnitedHealthcare to confirm.
I get Radio Frequency Ablation procedures done about once a year. Will Medicare cover the anesthesia?
Hi Poppy! Yes, as long as it’s considered medically necessary, Medicare will 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
Hi Georgia! There is no limit on the number of injections a patient can get as long as they are considered “medically necessary.”
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?
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.
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. 1-800-633-4227
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.