Does Medicare Cover Cervical Artificial Disc Replacement?
- Find out when Medicare may cover the cost of cervical artificial disc replacement. Learn which parts of Medicare may help pay for the surgical procedure.
Medicare may cover cervical artificial disc replacement if you live in certain areas and meet eligibility requirements.
Seven bones called cervical vertebrae form your cervical spine. In between these bones are cervical discs that act as cushions, minimizing shocks when you move your neck. Frequently, the cervical discs begin to break down with age, and in some people, this results in back and neck pain, neck stiffness, weakness of the limbs, headaches and other symptoms.
If you're suffering from the effects of a bulging or damaged disc, your doctor may diagnose you with degenerative disc disease and recommend surgery called cervical artificial disc replacement to ease discomfort.
Does Medicare Pay for Cervical Artificial Disc Replacement?
On the national level, cervical artificial disc replacement isn't covered because Medicare has ruled that the procedure is not medically necessary for people over the age of 60. Some local Medicare carriers have issued additional guidance that allows for coverage of the procedure for certain individuals.
These rulings only apply to places where the carrier issuing the coverage determination has jurisdiction. As a result, if you're enrolled in Original Medicare, you'll need to talk to your doctor or Medicare provider to find out if the service is covered.
How Does Cervical Artificial Disc Replacement Work?
During cervical artificial disc replacement surgery, your doctor removes the damaged disc and inserts an artificial metal or plastic disc in its place. This disc helps reduce pressure on your vertebrae and leads to a reduction in discomfort associated with degenerative disc disease.
Depending on your overall health, the procedure may be performed in a hospital on an outpatient basis, or you may need to be admitted to the hospital for one or two days during recovery.
Who Qualifies for Cervical Disc Replacement?
If you live in an area where cervical disc replacement is approved under the local coverage determination, all the following statements must be true for the procedure to be covered:
- The disc being used is approved by the FDA
- You're considered to be ''skeletally mature" — this typically applies to anyone over the age of 25
- You've either been experiencing pain that isn't relieved through over-the-counter medications and physical therapy for at least six weeks or your symptoms are progressing rapidly and the procedure is considered urgent
- You've undergone a CT scan, an MRI or myelography to diagnose your condition
- The damaged disc is in the right location on your spine
If you have certain medical conditions or have previously undergone back surgery, you may be ineligible for Medicare coverage even in areas where the procedure is approved.
Which Part of Medicare Does Cervical Artificial Disc Replacement Fall Under?
If your doctor elects to perform cervical artificial disc replacement on an inpatient basis, Medicare Part A will cover costs associated with your inpatient stay, such as the cost of your room and food. You may have to pay a copay or coinsurance if a lengthy hospital stay is required.
Medicare Part B covers cervical artificial disc replacement for qualified beneficiaries. Under this portion of Original Medicare, you're normally responsible for 20% of the cost of treatment, and your plan pays for the rest.
Medicare Advantage or Medicare Part C Plans may opt to cover the cost of cervical artificial disc replacement even in areas where the procedure isn't covered by Original Medicare. If so, your plan will have its own eligibility guidelines. You'll typically be responsible for a copay or coinsurance, and you may have to choose a doctor or hospital in your plan's network to receive coverage.
If your Medicare plan has a deductible, you'll need to satisfy it before coverage can begin under Parts A, B or C.
Does Private Insurance Cover Cervical Artificial Disc Replacement?
Some private insurers cover cervical artificial disc replacement.
Coverage for the procedure may only be available in certain geographic locations. For example, Blue Cross Blue Shield only includes cervical artificial disc replacement in select states.
Coverage for the procedure may not be offered in every plan that an insurer offers, and you'll likely have to meet eligibility criteria for the insurance provider to accept your claim.