Does Medicare Pay for Back Braces?

Many individuals experiencing back pain often wonder if their medical insurance covers supportive devices like back braces. Navigating healthcare coverage can be challenging, especially for specific medical equipment. This article clarifies how Medicare covers back braces, outlining the conditions for coverage and the financial responsibilities involved.

Medicare Coverage for Back Braces

Medicare covers back braces under its Part B benefits, classifying them as Durable Medical Equipment (DME). DME must be durable, primarily medical, suitable for home use, and last at least three years. Back braces meet these criteria, providing support and aiding in the treatment of various spinal conditions.

Coverage for a back brace hinges on medical necessity, requiring a prescription from a healthcare provider for a diagnosed medical condition. This prescription must specify the medical reason for the brace, such as to provide support for a frail or malformed back, limit excessive movement, or assist in healing after an injury or surgery. Both custom-fitted and off-the-shelf back braces can be covered, provided they are rigid or semi-rigid and meet the medical necessity criteria.

A physician’s order or prescription is required for Medicare coverage. This order documents medical necessity and should detail the specific type of brace needed and its expected duration. An in-person consultation with the prescribing physician is required, and the order for the brace should be placed within six months of this consultation.

The types of back braces that qualify as DME include lumbar sacral orthoses (LSO) and thoracic lumbar sacral orthoses (TLSO). These braces are prescribed for conditions such as chronic or acute low back pain, scoliosis, spinal stenosis, and post-operative stabilization. Braces intended solely for comfort or general support without a specific medical diagnosis are not covered.

Steps to Obtain a Covered Back Brace

Obtaining a back brace covered by Medicare begins with a consultation with your treating physician. During this visit, your doctor will evaluate your condition to determine if a back brace is medically appropriate. They will then provide a written prescription or order detailing medical necessity.

After receiving the prescription, it is important to select a supplier that is enrolled in Medicare and agrees to accept Medicare assignment. This means the supplier has an agreement with Medicare to accept the Medicare-approved amount as full payment for the brace. Suppliers who accept assignment can only bill you for the Medicare deductible and coinsurance.

The chosen supplier is responsible for submitting the claim directly to Medicare on your behalf. They will need all the necessary documentation from your healthcare provider to support the medical necessity of the brace. This process ensures that Medicare directly processes the payment for the approved amount.

For certain off-the-shelf back braces, prior authorization may be required before the brace is dispensed and billed. This process is handled by the supplier, who must obtain approval from Medicare before providing the equipment. While this step primarily involves the supplier, beneficiaries should confirm that prior authorization, if needed, has been secured.

Out-of-Pocket Costs for Back Braces

When Medicare Part B covers a back brace, beneficiaries have certain out-of-pocket costs. The first financial responsibility is the Medicare Part B annual deductible. For 2025, this deductible is $257.

Once the Part B deductible has been met, Medicare pays 80% of the Medicare-approved amount for the back brace. The beneficiary is then responsible for the remaining 20% coinsurance. This coinsurance applies to all Durable Medical Equipment covered under Part B.

Medicare Supplement Insurance, also known as Medigap plans, can help cover these out-of-pocket expenses, including the Part B deductible and coinsurance. The specific coverage provided by a Medigap plan depends on the plan type. Many beneficiaries choose these plans to help reduce their financial responsibility for Medicare-covered services.

Medicare Advantage Plans, which are offered by private insurance companies approved by Medicare, must provide at least the same coverage as Original Medicare. However, these plans may have different cost-sharing structures, such as copayments, and specific network rules or prior authorization requirements. Beneficiaries enrolled in a Medicare Advantage Plan should contact their plan provider directly to understand their specific costs and network limitations for back braces.

If a supplier does not accept Medicare assignment, they can charge more than the Medicare-approved amount, and the beneficiary would be responsible for the difference in addition to the coinsurance and deductible. It is important to confirm that your supplier accepts assignment to prevent unexpected higher costs. Additionally, if a brace is not deemed medically necessary by Medicare, the beneficiary would be responsible for the full cost.