Does Medicare Cover Nerve Ablation?

Nerve ablation is a medical procedure that uses heat, cold, or chemical agents to temporarily or permanently disable nerves responsible for transmitting pain signals. This minimally invasive technique aims to provide relief for chronic pain conditions when other treatments have not been successful. Many individuals exploring this option often inquire about coverage through their Medicare benefits. This article will provide a comprehensive overview of how Medicare addresses nerve ablation procedures.

Medicare Coverage for Nerve Ablation

Medicare may cover nerve ablation procedures when they are considered medically necessary. Coverage falls under Medicare Part B for outpatient services. If the procedure requires inpatient hospital admission, Medicare Part A would be applicable.

For Medicare to cover nerve ablation, specific medical necessity criteria must be met, requiring detailed documentation from the treating physician. The patient must demonstrate chronic pain that is moderate to severe and significantly interferes with daily life. Evidence must show that more conservative treatments, such as physical therapy, medications, or injections, have been attempted and failed to provide adequate relief.

Common conditions for which nerve ablation might be considered include chronic back pain from facet joints, sacroiliac joint pain, or persistent knee pain linked to genicular nerves. Before radiofrequency ablation (RFA) for facet joint pain, diagnostic nerve blocks are often required to confirm the nerve as the source of pain. These blocks need to show significant pain relief, such as an 80% improvement, to predict a favorable response.

The procedure must be performed by a qualified healthcare professional, and the facility must be approved by Medicare. While Medicare does not have a single National Coverage Determination (NCD), Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) are established by regional Medicare Administrative Contractors (MACs). These local policies outline specific conditions, diagnostic requirements, and appropriate CPT codes, such as 64624, that must be satisfied for coverage.

The doctor’s supporting evidence, including patient history, failed prior treatments, and diagnostic procedure results, determines coverage. This medical record ensures the procedure aligns with Medicare’s guidelines for medically reasonable and necessary services. Adherence to local policies and comprehensive documentation is crucial for coverage.

Costs and Financial Responsibilities

Understanding the financial implications of nerve ablation under Medicare involves examining Original Medicare, Medicare Advantage plans, and supplemental insurance options.

For beneficiaries with Original Medicare Part B, out-of-pocket expenses apply once the procedure is approved. In 2025, the annual Part B deductible is $257, which must be met before Medicare pays its share.

After the deductible is satisfied, Medicare Part B covers 80% of the Medicare-approved amount for the nerve ablation and associated physician services. The beneficiary is responsible for the remaining 20% coinsurance. Original Medicare does not have an annual out-of-pocket spending limit, so this 20% coinsurance can accumulate.

Medicare Advantage (Part C) plans, offered by private insurance companies, are an alternative to Original Medicare. These plans cover at least all services Original Medicare covers, including medically necessary nerve ablation. Medicare Advantage plans have different cost-sharing structures, which may include copayments or different coinsurance percentages, and operate within a network of providers.

Unlike Original Medicare, Medicare Advantage plans are required to have an annual out-of-pocket maximum, which provides financial protection. In 2025, this limit can be up to $9,350 for in-network services. Beneficiaries pay their Medicare Part B premium in addition to any premium charged by their Medicare Advantage plan.

Medigap, or Medicare Supplement Insurance plans, are sold by private companies and help cover some out-of-pocket costs associated with Original Medicare. These plans can reduce a beneficiary’s financial responsibility by covering the Part B coinsurance, and sometimes the deductible, depending on the plan chosen. It is not possible to have both a Medicare Advantage plan and a Medigap policy simultaneously.

Medicare Part D, which covers prescription drugs, is not relevant to the nerve ablation procedure itself. It covers any pain medications prescribed post-procedure, subject to the plan’s deductible, copayments, and formulary. Costs for medications are separate from procedural costs.

Steps to Secure Coverage

Securing Medicare coverage for nerve ablation involves collaboration with your healthcare provider. The physician’s role in documenting medical necessity, detailing unsuccessful prior conservative treatments, and providing a precise diagnosis is important. This medical record is foundational for coverage determination, supporting nerve ablation as the appropriate next step.

Prior authorization may be required, particularly with a Medicare Advantage plan. While Original Medicare less frequently requires prior authorization, many Medicare Advantage plans mandate this approval before services. Your provider’s office handles the prior authorization process, submitting documentation to your plan. Medicare Advantage plans make a standard prior authorization decision within seven calendar days and an expedited decision within 72 hours.

Working with your provider’s billing department is important. They can verify coverage details, ensure correct billing codes, and submit claims to Medicare or your Medicare Advantage plan. Confirm that the provider and facility accept Medicare assignment to prevent unexpected higher out-of-pocket costs.

After the procedure, you will receive an Explanation of Benefits (EOB) from Medicare or your Medicare Advantage plan. This document details what was billed, approved, paid, and your remaining financial responsibility. Reviewing the EOB helps you understand how your claim was processed and what costs you owe.

If coverage is denied, you have the right to appeal. The Medicare appeals process has multiple levels. For Original Medicare, the first step is a redetermination, filed with the Medicare Administrative Contractor (MAC) within 120 days of receiving the denial. If unfavorable, you can request a reconsideration by a Qualified Independent Contractor (QIC) within 180 days.

Should reconsideration result in a denial, you may request a hearing before an Administrative Law Judge (ALJ) if the amount in controversy meets a threshold. Further appeal levels include review by the Medicare Appeals Council and judicial review in federal court if the amount in controversy reaches a higher threshold. For Medicare Advantage plans, the appeal process begins directly with the plan, following their instructions. Submitting supporting evidence from your doctor and keeping records of all communications and documents is recommended.