Medicare covers medically necessary surgery, including different types of back surgery. Part A can help cover the hospitalization cost, and Part B can help with the cost of physical therapy, should it be needed.
There can be many reasons for a person to experience back pain, but visiting a doctor for a diagnosis could be important.
Treatment for back pain can include physical therapy and chiropractic adjustment. In some cases, a surgical option may be necessary. A doctor should explain the treatment they are recommending and why it will be beneficial.
This article discusses the types of back surgery available, aftercare, and help with extra costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers medically necessary surgeries, including back surgery.
The type of surgery recommended must match medically acceptable treatment for the diagnosis.
A surgeon’s office can tell a person if they believe Medicare will cover the recommended type of surgery.
Medicare does not usually offer preauthorization for inpatient procedures. As of July 1, 2020, Medicare uses prior authorization for some hospital outpatient procedures.
Medicare Part B pays for a person’s doctor visits to diagnose the back problem and recommend treatment.
Medicare Part A pays for a person’s care in the hospital.
It is hard to know how much surgery will cost. A person can speak to the doctor’s office, surgeon’s office, and hospital to estimate the cost.
Medicare Part C, also known as Medicare Advantage, combines the benefits of parts A and B, and therefore the same coverage rules apply.
If a person has Medicare Advantage, the policy may require prior authorization for surgery, and subsequent claims are sent to the insurer rather than to Medicare.
Private insurance companies administer Medicare Advantage plans and may offer additional benefits. The plan provider can advise a person of any extra benefits that may help with back surgery costs.
Most back surgeries are known as open surgery, meaning there is a long cut called an incision. Some procedures can be less invasive, and a person will generally have less pain and shorter recovery times.
There are several reasons a doctor may recommend back surgery. These can include:
- herniated or ruptured disk: The disks cushioning the bones of the spine may become damaged
- spinal stenosis: The spinal column narrows and puts pressure on the spinal cord and nerves
- spondylolisthesis: The bones of the spine slip out of place
- vertebral fractures: Breaks in the bones of the spine
- degenerative disk disease: Damage to the disks that happens as a person gets older
These conditions can trigger back pain or pain in the legs. Leg pain can occur when the nerves are affected. When this happens, a doctor may recommend back surgery to relieve the pressure on a nerve.
Some of the different types of back surgery include:
- laminectomy: Sometimes recommended for spinal stenosis, a surgeon removes some of the spine’s bone to make room for the nerves
- foraminotomy: To reduce nerve pressure, the hole where the nerves exit the spine is made bigger. This surgery is requently recommended to treat a herniated disk or degenerative disk disease
- vertebroplasty and kyphoplasty: A surgery used to repair fractures of the spine caused by osteoporosis
- discectomy: The removal of a herniated disk, relieving pressure on nerves
- fusion: Removal of a spinal disk, in which the two bones are fused with grafts or metal screws.
- artificial disk replacement: An alternative treatment for those with a damaged disk that helps restore movement in the spine and relieves pressure on nerves
Immediately after surgery, a person may require pain medication. This can include:
- nonsteroidal anti-inflammatories (NSAIDs)
- local anesthetic
Part A will cover prescription drugs prescribed while an inpatient. Part B covers limited medication but will include medicines that a doctor must administer in-office.
Medicare Part D, also known as prescription drug plans (PDPs), covers other outpatient drugs.
Like Medicare Advantage, private insurance companies administer Part D plans, which are available when a person is first eligible for Medicare. Part D plans can be standalone or included within Medicare Advantage.
Individuals without a PDP may have to pay for medication out of pocket.
After back surgery, a person may need physical therapy to build strength and stay independent. Part B will pay for medically necessary physical or occupational therapy.
There are out-of-pocket costs associated with Medicare.
Part A has a deductible for each benefit period of $1,408. A person does not pay any coinsurance for the first 60 days in the benefit period.
The day a person is admitted to the hospital is when the benefit period begins. It ends when an individual has not been in the hospital for 60 days in a row.
A person must first pay their Part B deductible for outpatient aftercare, with a 20% coinsurance applying to further eligible expenses. There may also be a copayment for each service, such as $15 to see the physical therapist.
A person may have some options to help pay extra surgical and aftercare costs associated with back surgery.
Medigap policies, also known as supplemental insurance, can help with out-of-pocket expenses associated with original Medicare.
Private insurance companies administer Medigap plans that currently offer assistance with:
- excess charges
Some states let doctors charge more than Medicare allows. The extra is called an excess charge. If a person does not have a Medigap policy that pays this cost, they must pay out of pocket.
As of January 1, 2020, no Medigap plan covers the Part B deductible.
An individual may have a secondary healthcare policy that covers expenses Medicare may not.
By checking with the secondary plan provider, a person may find additional benefits for therapeutic services.
People who have limited resources and income may qualify for Medicaid, Supplemental Security Income (SSI), or Extra Help.
Medicaid is a health insurance program that helps pay medical costs for those who meet the eligibility criteria.
Coverage is for all ages, and as of April 2020, Medicaid covers 65.6 million Americans.
Supplemental Security Income (SSI)
If eligible, SSI is a benefit that a person will receive monthly.
Generally, as person must be age 65 or older and have a disability.
A person can use the Social Security Administration website to find out if they are eligible.
Extra Help applies to a person’s prescription drug plan only.
The program could help with Part D costs, including:
- monthly premiums
Medicare parts A and B pay for medically necessary back surgery.
Part A covers hospitalization costs, and Part B pays for medically necessary physical and occupational therapies that help improve strength after surgery.
There are extra costs associated with parts A and B, but Medigap plans can help pay those costs.
People who have a disability, limited income, and few resources may be eligible for other programs to help pay costs, including Medicaid, Extra Help, or Supplemental Security Income.