Back pain is a significant health concern for many Medicare beneficiaries, often affecting mobility and quality of life. Many beneficiaries investigate various treatment options, including spinal decompression therapy (SDT). Coverage for SDT under Medicare is complex and depends entirely on the specific method used. This article explains how Medicare evaluates and covers different forms of spinal decompression.
Defining Spinal Decompression Therapy
Spinal decompression therapy (SDT) is a treatment designed to alleviate pain by reducing pressure on the spinal discs and nerves. The goal is to create negative pressure within the disc space, helping to reposition bulging or herniated discs and allowing nutrients to flow into the disc. SDT is typically recommended for chronic low back pain, sciatica, and degenerative disc disease.
SDT is divided into non-surgical and surgical categories. Non-surgical decompression uses mechanical traction devices that gently stretch the spine, usually performed in an outpatient setting. Surgical decompression involves operative procedures like laminectomy, discectomy, or foraminotomy, which physically remove material pressing on the spinal cord or nerve roots to permanently relieve compression.
Medicare’s Stance on Non-Surgical Decompression
Non-surgical SDT, which uses mechanized traction tables, is generally not covered by Original Medicare (Parts A and B). Medicare policy, guided by National Coverage Determinations (NCDs), often regards these mechanical traction therapies as lacking sufficient scientific evidence. Consequently, the procedure is considered not medically reasonable or necessary for payment purposes. This non-coverage position is the default rule, as Medicare does not typically cover treatments it considers experimental or investigational.
Medicare only covers manual manipulation of the spine by a chiropractor to correct a vertebral subluxation. Mechanical traction falls outside of this covered service. Providers must inform patients seeking non-surgical decompression that they will likely be responsible for the full cost of the treatment.
Coverage for Surgical Spinal Decompression
Surgical spinal decompression procedures are covered by Medicare when deemed medically necessary. These operations provide permanent relief from severe nerve compression that has not responded to conservative treatments. Common covered procedures include laminectomy (removing a portion of the vertebral bone) and microdiscectomy (removing disc material pressing on a nerve). Coverage depends on the location: inpatient hospital stays fall under Medicare Part A, while outpatient procedures and the surgeon’s professional fees are covered under Medicare Part B.
To qualify, medical necessity must be clearly documented, requiring evidence of failed conservative treatment attempts and diagnostic imaging showing clear spinal compression. Percutaneous image-guided lumbar decompression (PILD) is an exception. This minimally invasive technique is only covered under a policy known as Coverage with Evidence Development (CED), meaning it is covered primarily when performed within an approved clinical study or trial.
Navigating Non-Covered Costs and Appeals
When a provider believes a service, such as non-surgical spinal decompression, will not be covered because it is not medically necessary, they must issue an Advance Beneficiary Notice of Noncoverage (ABN). The ABN informs the beneficiary that Medicare is expected to deny payment and shifts the financial liability to the patient. The ABN gives the beneficiary two choices: receive the service and accept financial responsibility if Medicare denies the claim, or refuse the service to avoid the cost.
Signing the ABN means the patient agrees to pay if Medicare ultimately denies the claim, ensuring an informed decision before incurring unexpected expenses. If a claim is denied, the beneficiary has the right to appeal Medicare’s decision, starting with a request for redetermination. However, understanding coverage limitations beforehand is the most financially secure action, as the appeals process can be lengthy and may still result in the patient being responsible for the bill.