Does Medicare cover treatment for back pain?

Back pain is extremely common among older adults. In 2019, data from the National Health Interview Survey, revealed that 39 percent of U.S. adults had back pain, and that adults aged 65 or older were one of three core groups identified as most likely to experience back pain. Moreover, about 16 million adults experience chronic back pain, and adults with back pain are more likely to use health care services than adults without back pain.

Because back pain is so prevalent, it’s not surprising that in recent years, the Centers for Medicare and Medicaid Services (CMS) have expanded coverage for back pain treatments. For example, coverage for acupuncture for chronic low back pain was expanded in 2020 along with peripheral nerve stimulation (PNS) treatments.

There are a variety of options for treating acute, sub-acute and chronic back pain. Some are non-surgical and minimally invasive. Some require surgery.

Original Medicare (Medicare Part A and Part B), Medicare Advantage plans (Part C) and Medicare Part D prescription drug plans each may cover different pain management services and treatments. What is covered and how much it costs may depend on the treatment you get, the Medicare coverage you have, and how the treatment is administered.

Medicare coverage will also vary for each treatment and is often accompanied by strict requirements for coverage to be provided. This is important to note as the requirements Medicare sets for each kind of back pain treatment must be met for your Medicare coverage to be used. Some of the things Medicare may require for a back pain treatment to be covered include:

• The treatment must be medically necessary
• Your pain must be of a certain level and/or duration (i.e., if the pain is chronic – lasting 6 weeks or more)
• You have tried less-invasive interventional treatments first (i.e., physical therapy) and they’ve been unsuccessful
• The treatment you receive to be done a certain way

Note: Just because the back pain treatment is covered, accompanying medical provisions such as anesthesia may not be if they’re not considered medically necessary.

It is paramount you speak with your doctor and Medicare insurance provider before undergoing any treatment to properly understand what will and will not be covered, and what costs you may be fully or primarily responsible for.

Now, let’s look high-level at some of the back pain treatment options Medicare may or may not cover.

Common non-surgical back pain treatments include physical therapy, massage therapy, acupuncture, chiropractic therapy, prescription drug therapy (medications), injection-based treatments, laser therapy, electrical nerve stimulation, peripheral nerve stimulation, radio frequency ablation, and non-surgical blocks (i.e., nerve blocks or medial branch blocks).

View the following table to see how Medicare coverage works for some of the most common non-surgical back pain treatments.

Many non-surgical back pain treatments are covered either by Medicare Part B, or a Medicare Advantage plan. Services that require medications may either be covered by a Medicare Advantage plan that includes prescription drug coverage or a stand-alone Part D plan.

Again, it’s important to make sure your Medicare coverage will cover a treatment before getting it. Talk with your doctor and your plan provider to make sure you’re not going to get caught off-guard.

Some back pain treatments are surgical in nature. These may or may not be covered by Medicare, and often will require you to try less-invasive treatment options first. Some examples of surgical back pain treatments include spinal cord stimulation (SCS), dorsal root ganglion stimulator (DRG), surgical blocks, decompression surgery (such as microdiscectomy or a laminectomy), spinal fusion or the surgical implantation of artificial disks.

Surgery is typically considered a last resort and is only approved on a case-by-case basis, when your health care provider determines no other treatment will work. Medicare may cover back surgery that is deemed medically necessary based on a recommendation from your neurosurgeon or orthopedist. You should consult with your doctor and Medicare insurance provider to understand whether or not your treatment will be covered prior to the service.

As mentioned above, there are many back pain treatment options available and how Medicare may cover each varies. When considering a back pain treatment option, keep the following in mind:

1. What kind of Medicare coverage you have (Original Medicare vs Medicare Advantage)
2. What requirements are necessary for the treatment to be covered
3. If any accompanying medical services needed for the back pain treatment is not covered

When it comes to getting Medicare to cover back pain treatments, it’s paramount you speak with the physician providing your back pain treatment(s), Medicare, and your Medicare plan provider if you have a Medicare Advantage or Part D plan.