Medicare coverage for lower back pain management is available when necessary. Yet, some costs you may pay for entirely.
By the time most people reach eligibility, they’ve had some lumbar pain. Those feeling lower back pain need to know about treatments and pain management therapies. The cause of the back pain determines a patient’s eligibility for treatments and therapies.
Medicare Coverage for Lower Back Pain Treatment Options
There are many treatment options, including:
- Physical Therapy
- Chiropractic Treatments
- Medications
- Injection Based Treatments
- 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 over 50% improvement, you want to avoid surgery at all costs.
Also, 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 all traditional treatments, including interventional pain management, and they’ve failed.
Medicare will cover lower back surgery when it’s medically necessary. We’ll go over coverage for the treatments you should seek before you resort to surgery to help your lower back pain.
Medicare Coverage Guidelines for Lower Back Pain Management Injections
Per the standard Medicare guidelines, cortisone injections usually receive coverage without prior authorization. Also, different doses have different costs. Make sure to ask your doctor about the allowable amount for each procedure.
Supplement coverage is crucial for those with lower back pain management needs. When undergoing pain management treatments, supplemental insurance protects you financially.
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.
Types of Pain Management Injections
- 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.
Medicare Coverage for Pain Management Injections
Usually, Medicare covers pain management injections when they’re determined to be medically necessary. Suppose you’re receiving an injection during an inpatient stay at a hospital. In that case, it will receive coverage from Part A. If your doctor administers the procedure in an outpatient setting, Part B covers the injection.
Does Medicare Cover Radiofrequency Ablation?
When a doctor deems RFA medically necessary, it gets coverage. 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. If you have an Advantage plan, costs may vary, so contact your plan for details.
Medicare Coverage for SIJ Injections
Sacroiliac joint injections are also known as SIJ injections. They are therapeutic injections that treat pain and inflammation. The practitioner injects numbing medication and cortisone into the sacroiliac joint, which is located by the buttocks. If doctors consider this injection necessary for pain relief, it will get coverage from Medicare.
Medicare Coverage for Lumbar Facet Injections
Lumbar facet injections diagnose the joints as the patient’s pain source. The procedure is necessary if facet joint syndrome is suspected as the cause of back or neck pain.
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
Medicare Coverage for Lumbar Medial Branch Blocks
Lumbar medial branch blocks refer to a diagnostic procedure where injection of an anesthetic “tests” the joint’s nerve endings. This is done to verify the pain relief response and receives coverage when medically necessary. When the patient feels relief, they’re a candidate for radiofrequency ablation.
Does Medicare Cover Lumbar Epidural Steroid Injections?
Some requirements must be met for the coverage to begin. For example, 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.
Medicare Coverage for Conditions of Lower Back Requiring Pain Management Treatments
Below, we’ll go over some spine-related ailments the details of coverage for each treatment.
Sciatica
Only those feeling pain starting from the sacroiliac joint, or SIJ, have true sciatica. Those suffering from sciatica can obtain coverage for lumbar epidural steroid injections.
Disc Herniation
Sometimes, surgery, known as a discectomy, is performed to fix a herniated disc. But, Medicare doesn’t cover discectomies because patients can often get relief for a herniated disc through non-surgical approaches. These avenues for relief include exercise, physical therapy, massage, and pain medication. Epidural steroid injections can also help.
Lumbar Stenosis
Medicare doesn’t consider the treatment of percutaneous image-guided lumbar decompression (PILD), so there is no coverage.
Facet Joint Arthropathy
If medically necessary, epidural steroid injections for this condition obtain coverage from Medicare. Physical therapy may also help with this condition but might not get coverage unless a doctor refers you.
Lumbar Spondylolisthesis
Medicare doesn’t cover lumbar artificial disc replacement (LADR) surgery. Alternative treatments are pain management medications and physical therapy. The latter have coverage when a doctor refers you to help get back on your feet.
FAQs
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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!
Hello, I’ve been getting facet joint infections, nerve blocks and radio ablation for a couple of years, Now that I’ve been put on Medicare (I’m under 65), the premiums are a bit much. I have a plan N. To get some financial relief, I’m contemplating getting an Advantage plan for the next 12 months, then going back to Medigap.. I know it’s a risk, but I’m supporting 2 thanks to the pandemic and need some help there (not able to get Medicaid in my state). Question is: With as common as these injections are, are there Advantage plans that cover more? I require sedation so that drives the cost up. I will note that I’m on the only Supplement plan in my state that’s offered to younger than 65 folks..
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.