Does Medicare Cover Pain Management?

Medicare serves as the primary health insurance for millions of Americans, providing coverage for a broad spectrum of medical services. Medicare helps cover many pain management options, including therapies, procedures, and medications, with specific coverage depending on the type of treatment received.

Understanding Medicare Parts

Medicare is structured into several parts, each covering different types of health services that may be relevant to pain management. Original Medicare consists of Part A and Part B.

Part A, known as Hospital Insurance, primarily covers inpatient care received in hospitals, skilled nursing facilities, and some home health and hospice care. This part of Medicare would cover pain management services administered during an inpatient hospital stay, such as after a surgery.

Part B, or Medical Insurance, covers outpatient services, including doctor visits, medical supplies, and certain preventive services. Many pain management treatments, such as physical therapy, occupational therapy, and various injections, fall under Part B coverage.

Medicare Part C, also known as Medicare Advantage, offers an alternative to Original Medicare. These plans are provided by private companies approved by Medicare and are required to offer at least the same coverage as Parts A and B, often including additional benefits like prescription drug coverage.

Medicare Part D provides prescription drug coverage. These plans are offered by private insurance companies and help beneficiaries pay for self-administered prescription drugs, which include many pain medications. Beneficiaries can obtain Part D through a stand-alone plan or as part of a Medicare Advantage plan that includes prescription drug benefits.

Specific Pain Management Treatments Covered

Medicare covers a variety of pain management treatments. Physical therapy and occupational therapy are covered by Medicare Part B when medically necessary and prescribed by a healthcare provider. These therapies aim to improve strength, mobility, and the ability to perform daily activities.

Chiropractic services are covered by Medicare Part B specifically for manual manipulation of the spine to correct a vertebral subluxation. Acupuncture is also covered under Part B for chronic low back pain that has lasted for 12 weeks or longer, is not associated with surgery or pregnancy, and has no known systemic cause. Medicare covers up to 12 sessions within a 90-day period, with an additional 8 sessions if improvement is shown, up to a maximum of 20 treatments per year. The treatment must be provided by a doctor or other healthcare provider with specific acupuncture credentials.

Various pain injections, such as epidural steroid injections, facet joint injections, and nerve blocks, are covered by Medicare Part B when medically necessary. For instance, epidural steroid injections may be covered for severe pain lasting over four weeks due to specific conditions, with coverage typically limited to four sessions every 12 months. Medicare Part B also covers durable medical equipment, such as wheelchairs or walkers, used for pain relief, provided it is medically necessary and prescribed by a doctor for home use.

Prescription medications for pain are primarily covered under Medicare Part D. Part D plans maintain formularies, which are lists of covered drugs, and costs can vary based on the drug’s tier. Medicare also covers Chronic Pain Management (CPM) services under Part B, which include comprehensive care planning, medication management, and coordination among providers for long-term pain conditions.

Medicare Requirements for Pain Management Coverage

Medicare imposes specific conditions and criteria for pain management services to be covered. A primary requirement for most pain management treatments is medical necessity. This means the treatment must be considered appropriate and necessary for diagnosing or treating a medical condition, meeting accepted standards of medical practice. Healthcare providers must document a clear diagnosis, a treatment plan, and measurable goals to justify the services.

For certain complex procedures or therapies, prior authorization may be required before Medicare will cover the service. This process ensures the proposed treatment meets Medicare’s medical necessity guidelines and is appropriate for the patient’s condition.

All covered pain management services must be provided by healthcare professionals and facilities enrolled in and approved by Medicare. Detailed documentation is essential for Medicare coverage, particularly for ongoing therapies.

Providers must maintain thorough records, including treatment plans, progress notes, and assessments of functional improvement. If annual therapy costs exceed certain thresholds, such as $2,410 for physical and speech therapy combined in 2025, additional documentation confirming medical necessity is required for continued coverage. In some cases, Medicare may also require that more conservative treatments be attempted and documented as ineffective before approving more invasive pain management procedures.

Costs Associated with Pain Management

Even with Medicare coverage, beneficiaries typically incur out-of-pocket costs for pain management services. Under Original Medicare, these costs include deductibles, copayments, and coinsurance.

For 2025, the Medicare Part A deductible for inpatient hospital stays is $1,676 per benefit period. Part B has an annual deductible of $257 in 2025, which beneficiaries must meet before Medicare begins to pay its share.

After meeting the Part B deductible, beneficiaries are generally responsible for a 20% coinsurance of the Medicare-approved amount for most outpatient pain management services. For prescription drugs covered under Part D, costs can vary significantly by plan, often involving premiums, deductibles, and tiered copayments or coinsurance depending on the drug’s classification.

Medicare Advantage (Part C) plans may have different cost structures compared to Original Medicare, often featuring their own deductibles, copayments, and coinsurance amounts. Many Medicare Advantage plans also include an annual out-of-pocket maximum, which can provide financial protection by limiting a beneficiary’s total yearly spending on covered services.

Medicare Supplement Insurance, also known as Medigap, can help beneficiaries with Original Medicare cover some of these out-of-pocket expenses. Medigap policies are offered by private companies and can help pay for deductibles, copayments, and coinsurance amounts that Original Medicare does not cover. Additionally, some higher-income beneficiaries may pay an Income-Related Monthly Adjustment Amount (IRMAA) in addition to their standard Part B and Part D premiums.