Medicare pain coverage

If you have chronic pain, you are not alone. In fact, a study published in 2022 by the International Association for the Study of Pain shows that approximately one in five American adults are living with chronic pain. Pain management has come a long way in recent years, offering a range of treatments for specific types of pain. But if you are on Medicare, you likely have a lot of questions about your coverage. Does Medicare cover acupuncture for neck pain? Does Medicare cover stem cell therapy for back pain? To answer these questions and more, let’s take a deep dive into how Medicare works and what you can expect from Medicare pain management.

The ABCs of Medicare Pain Coverage

To understand pain management under Medicare, you first need to understand the various parts of Medicare and how they all work together. Medicare is a government-sponsored health insurance program available to those aged 65 and above, as well as younger people with qualifying disabilities. But there are multiple parts, and only two of them (Parts A and B) make up original Medicare.

Medicare Part A is free for everyone who worked and paid Medicare taxes, meaning the individual would have had to pay 10 years of Medicare taxes (120 total months) to be eligible for Premium-Free Part A, as soon as you turn 65 or develop a qualifying disability. It is hospitalization insurance that covers medically necessary stays in the hospital, as well as hospice and a few other services.

Medicare Part B is general medical insurance. You will become eligible for Part B along with Part A, but Part B is not free or automatic. You will need to enroll and pay a monthly premium (which may vary based on your income), along with a small deductible. This part covers medically necessary services ranging from doctor visits to preventive screenings to imaging tests.

Original Medicare covers many aspects of pain management therapy. But this coverage may be incomplete, as specific treatments that your doctor recommends may not be covered. In addition, original Medicare requires you to pay a coinsurance of 20% for each service, with no annual limit on how much you will pay out of pocket. Since chronic pain requires ongoing pain management, these costs can be quite pricey. Finally, original Medicare does not cover prescription drugs, which are considered a main line of defense against many types of chronic pain.

There are additional Medicare products that you can purchase through private insurance companies such as Blue Cross and Blue Shield of Kansas, which help plug the gaps in original Medicare. These include Medicare Part C, or Medicare Advantage, as well as Medicare Part D, or prescription drug coverage. And many Medicare Advantage plans include Part D coverage, so you may not need to purchase it separately. There is also an alphabet soup of Medicare supplement, or Medigap, plans that enhance but do not replace original Medicare. These products may provide more comprehensive pain management solutions, as well limits on your out-of-pocket annual costs.

Medicare pain management

So what can you expect from pain management through Medicare? You will find that a lot of options are covered, though they may or may not be the specific solutions that you and your doctor want to pursue.

Does Medicare cover chronic pain management?

Original Medicare covers some aspects of chronic pain management. Part A covers hospital stays that may be required if your pain becomes unmanageable or a specific underlying condition needs hospital treatment. Part B covers certain types of testing, as well as some types of pain management therapies. But your coverage will likely be more complete with additional parts of Medicare. For example, Part C may cover additional therapies, while Part D covers a variety of prescription pain medications, including certain medically necessary opioids.

Does Medicare cover pain management specialists?

If you have chronic pain, it only makes sense to see a pain management specialist. Medicare may cover these visits if the practitioner is a licensed medical doctor who accepts Medicare patients. Note that some doctors accept Medicare assignment, which means that the provider agrees to Medicare’s standard payment rates and bills Medicare directly. If your provider accepts Medicare patients but not Medicare assignment, you may pay up to 15% more than the negotiated Medicare rates. You might also need to pay upfront and then submit a claim to Medicare for reimbursement. Note that all visits must be deemed medically necessary by Medicare in order for claims to be paid.

Does Medicare cover MRI for back pain? What about an ultrasound or x-ray?

Medicare Part B typically covers charges for MRIs, ultrasounds, and x-rays if they are medically necessary. These imaging tests must be ordered by a medical doctor rather than a chiropractor, and you will be responsible for paying your normal coinsurance (generally 20% of the total charges) for each test.

Does Medicare cover mattresses for back pain?

It depends. Medicare Part B covers durable medical equipment. An orthopedic mattress may qualify, depending on the specifics of your condition. Pain issues such as arthritis and sciatica typically qualify if your doctor determines that the mattress is medically necessary. The mattress must also meet specific criteria, including:

  • You will use it for at least three years
  • Designed to help people who are sick or injured
  • Used for medical reasons
  • Durable and able to withstand heavy usage
  • Able to be used in the home

In some cases, you may qualify for an adjustable bed and mattress, while in other cases, it will be a mattress that fits your existing bed frame. You must purchase the mattress from a Medicare-approved supplier, and you will be responsible for your coinsurance.

Medicare and specific pain management treatments

Now you know that Medicare offers some coverage for pain management. But you probably have a lot of specific questions. Does Medicare cover acupuncture for shoulder pain? What were the Medicare guidelines for pain management injections in 2022? In short, will Medicare cover the pain management treatments that you and your doctor feel are best? Let’s take a look.

Does Medicare cover physical therapy for back pain or other pain conditions?

Medicare Part B covers physical therapy when it is medically necessary, including for back pain and other types of pain. You will be responsible for paying your coinsurance. In addition, you need to know about something called a Medicare therapy threshold.

Before 2018, Medicare set a hard dollar limit for therapy services each year. Once you hit that limit, Medicare would no longer pay for physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) for the rest of the calendar year. In 2018, though, the hard cap was removed and replaced with a threshold limit. For 2022, the threshold was $2,150 for PT and SLP combined, with a separate threshold of $2,150 for OT. When you hit the threshold, your provider must complete documentation showing the medical necessity of continuing therapy. When you reach $3,000 in covered therapy services, Medicare may conduct a targeted medical review.

What all this means for you is that there may be a couple of temporary delays in your physical therapy schedule while everything is processed. But there is no hard limit on how many sessions are covered if you are still in medical need.

Does Medicare cover acupuncture for knee pain or other types of pain?

Medicare Part B covers up to 12 sessions of acupuncture within 90 days for chronic lower back pain only. You can add another eight sessions if you are showing signs of improvement, for a maximum of 20 sessions in a 12-month period. However, original Medicare does not cover acupuncture for any other type of acute or chronic pain. If you have a Medicare Advantage plan, you may have additional coverage.

Does Medicare cover laser therapy for pain?

Cold laser therapy is a relatively new solution for pain that does not respond to more traditional treatments. Unlike surgery, it is non-invasive and painless. Cold laser therapy is being used to treat a variety of conditions, from lower back pain to tennis elbow. But it is still considered experimental and is not covered by Medicare.

Does Medicare cover injections for pain, such as trigger point or sacroiliac (SI) joint injections?

In general, Medicare will cover medically necessary injections for pain. You must have a diagnosis and treatment plan from a licensed medical doctor, and preauthorization may be required. The number of injections you can receive in a year may be limited according to your condition, the affected body part, and the specific type of injection you are receiving.

Does Medicare cover stem cell therapy for pain?

Stem cell therapy is a form of regenerative medicine, which has gotten a lot of attention lately. The idea is that since stem cells can turn into other kinds of cells, they may be able to replace cartilage and other tissues that have been damaged by injury or disease. It’s an interesting theory, but stem cell therapy is still highly experimental. Therefore, it is not covered by Medicare at this time.

Learn More About Medicare Pain Coverage

Chronic pain is miserable, and it can even be life-limiting. In general, original Medicare does a decent job of covering pain management treatments. But your preferred treatments may not be covered, and the out-of-pocket costs can add up fast. To learn more about how a Medicare Part C (Medicare Advantage) plan can help plug the gaps in original Medicare coverage, call BCBSKS today at 866-627-6705.

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