Does Medicaid Cover Back Surgery?

In this article...
  • Medicaid coverage for back surgery varies from one state to the next. Learn about the coverage Medicaid provides for emergency and elective back surgery.

Does Medicaid cover back surgery? It depends. Medicaid does cover medically necessary surgeries, but its coverage for back surgery appears to vary drastically depending on what state you're in. Keep reading to learn some of the specifics regarding Medicaid's coverage of back surgery.

Does Medicaid Cover Back Surgery?

Medicaid provides partial coverage for surgical services, including back surgery, that doctors have determined are medically necessary. Emergency surgery is almost always covered by Medicaid. This is surgery performed when Medicaid enrollees have acute symptoms caused by a preexisting condition or by trauma, and it's intended to prevent significant injury or loss of life.

Elective back surgery may also be covered by Medicaid if the state Medicaid Agency determines that it's medically necessary. However, what the state Medicaid Agency decides is medically necessary may differ from what a physician considers necessary. The amount and terms of coverage can be affected by the specific type of surgery being performed and the circumstances involved. Whether it's performed in a hospital or an outpatient surgical center may also affect the level or existence of coverage.

Each state varies in terms of what back surgeries it covers. States are required to provide services that Medicaid considers mandatory. However, some states cover various treatments or diagnostic procedures while others consider those same treatments and procedures optional.

Medicaid beneficiaries who are also eligible for Medicare may be able to receive coverage for back surgery from both programs. Medicaid may help pay for the following.

  • Medicare Part A and Part B premiums
  • Medicare Part A and Part B deductibles
  • Medicare Part A and Part B copays
  • Hospital stays that are longer than Medicare Part A covers

How Does Back Surgery Coverage Vary Between States?

A 2019 study by Dr. David S. Casper at Thomas Jefferson University Hospital in Philadelphia looked at the variation of Medicaid reimbursement for common spinal surgeries in many states. It revealed that across 43 states Medicaid paid an average of only 78% of what Medicare paid for the same spinal surgeries.

However, from one state to the next, the payment for back surgery varied greatly. Medicaid payment was significantly low in Florida, New Jersey, New York and Rhode Island. In only four states — Alaska, Arkansas, Nebraska and South Dakota — Medicaid actually paid more than Medicare did.

The variation of payment may make it more difficult for Medicaid enrollees to get the back surgery they need in some states. When physicians receive low reimbursement for their services from Medicaid, they are less likely to be willing to take Medicaid enrollees.

How Much Does Back Surgery Cost Without Insurance?

The cost of back surgery can vary greatly depending on what part of the country you're in and what type of surgery you require. Surgery in parts of the country with high costs of living (think major cities such as Los Angeles or New York) can run two to three times as much as in less crowded areas.

Back surgery for a herniated disc can range from $15,000 to $45,000. The most common neck surgery, known as anterior cervical surgery, runs anywhere from $20,000 to $45,000. If you have spinal stenosis and need a laminectomy, expect a bill ranging from $50,000 to $90,000. A single lumbar fusion may cost $65,000 to $100,000 or even more if titanium implants are used.

Remember, the costs for your hospital stay and the fees you pay to your surgeon, your anesthesiologist and any other physician are figured separately. But you won't find much in the way of savings if you choose minimally invasive back surgery rather than traditional surgery because the costs are roughly the same. In addition, you may have to pick up the tab for physical therapy, medical equipment such as a back brace, and medications, including painkillers.

Is Back Pain Covered by Medicare?

Medicare covers some treatment for back pain but not all types of treatment. Among the back pain treatments you can generally expect Medicare to cover are:

  • Medication
  • Physical therapy
  • Acupuncture
  • Cortisone injections
  • Lumbar medial branch blocks for diagnostic purposes
  • Therapeutic radiofrequency ablation
  • Chiropractic treatment
  • Surgery

Whether a particular treatment is covered for your back pain depends largely on your physician's diagnosis and the type of Medicare plan you have. Surgery is generally covered only after many other treatments have proven ineffective.

The number of treatments you may receive per year depends largely on your diagnosis and where you receive the therapy or treatment. Medicare must approve some treatments for back pain in advance.

Medicare does not cover certain procedures related to back pain, even if they are prescribed by a physician. Medicare will generally refuse to cover the following treatments.

  • Artificial lumbar disc replacement surgery
  • Piriformis Syndrome surgery
  • Lumbar stenosis decompression
  • Discectomy to correct a herniated disc
  • Massage therapy
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