Does Medicare Pay for Spinal Decompression?

For Medicare enrollees, understanding coverage for specialized procedures like spinal decompression is important. Clarifying which medical services are covered helps manage expectations and financial planning, enabling informed decisions about care.

Understanding Spinal Decompression

Spinal decompression refers to various treatments designed to relieve pressure on the spinal cord or nerves. This pressure can arise from conditions such as bulging or herniated discs, degenerative disc disease, sciatica, and spinal stenosis.

Spinal decompression approaches fall into two main categories: non-surgical and surgical. Non-surgical methods involve a specialized table that gently stretches the spine, employing traction to create negative pressure within spinal discs. This can help retract disc material and promote nutrient flow. Surgical spinal decompression involves operative procedures to remove bone or disc material that is compressing nerves. Common surgical techniques include laminectomy, discectomy, foraminotomy, and spinal fusion.

Medicare Coverage Framework

Medicare provides health insurance coverage primarily for individuals aged 65 or older, and for some younger people with disabilities. The program is structured into different parts, each covering specific types of services. Medicare Part A, Hospital Insurance, covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services.

Medicare Part B, Medical Insurance, covers medically necessary doctors’ services, outpatient care, durable medical equipment, and some preventive services. Individuals can choose Medicare Advantage Plans (Part C), offered by private companies approved by Medicare. These plans are required to cover at least all services Original Medicare covers. A central principle for Medicare coverage across all parts is medical necessity, meaning the service or item must be required for the diagnosis or treatment of a medical condition.

Medicare’s Stance on Spinal Decompression

Medicare’s approach to covering spinal decompression therapies varies significantly between surgical and non-surgical methods. Original Medicare does not cover most non-surgical spinal decompression therapy, particularly those involving mechanical traction devices. These treatments are considered experimental or lack sufficient evidence of effectiveness. While some manual therapies incorporating decompression principles might be covered if medically necessary, machine-based non-surgical decompression is not.

Surgical spinal decompression procedures are covered by Medicare when medically necessary. Common surgical interventions like laminectomy, discectomy, foraminotomy, and spinal fusion are included if a physician determines they are medically necessary.

For coverage, specific criteria must be met: documented medical necessity, evidence that conservative treatments have failed, clear diagnostic imaging supporting the need for surgery, and a recommendation from a qualified healthcare provider. The procedure must also be performed at a Medicare-approved facility.

Percutaneous image-guided lumbar decompression (PILD) has limited coverage. Medicare only covers PILD when performed as part of an approved clinical trial, under a policy known as Coverage with Evidence Development (CED). Medicare Advantage plans must provide at least the same level of coverage as Original Medicare for medically necessary services, including surgical decompression.

Costs and Patient Responsibilities

Even when a spinal decompression procedure is covered by Medicare, beneficiaries incur out-of-pocket costs. For services covered under Medicare Part A (inpatient hospital stays), the deductible for 2025 is $1,676 per benefit period. Coinsurance amounts apply for longer hospital stays, with $419 per day for days 61-90 and $838 per day for lifetime reserve days. Most individuals do not pay a monthly premium for Part A if they have sufficient work history.

For services covered under Medicare Part B (outpatient procedures and doctor visits), beneficiaries are responsible for an annual deductible of $257 in 2025. After meeting this deductible, Part B covers 80% of the Medicare-approved amount for covered services, leaving the beneficiary responsible for the remaining 20% coinsurance. The standard monthly premium for Medicare Part B is $185.00 in 2025, though higher-income individuals may pay more. Medicare Advantage plans have varying cost structures, including different premiums, deductibles, and copayments, with an out-of-pocket maximum for in-network services that can reach up to $9,350 in 2025. Additionally, if a provider does not accept Medicare assignment, they may balance bill, charging up to 15% above the Medicare-approved amount, which is the patient’s responsibility.

Appealing a Denied Claim

If Medicare denies coverage for a spinal decompression procedure or related service, beneficiaries have the right to appeal the decision. The appeal process involves several levels, providing multiple opportunities to challenge a denial. The first step is a redetermination by a Medicare Administrative Contractor (MAC), followed by a reconsideration by a Qualified Independent Contractor (QIC).

If the denial persists, further appeals can be made to an Administrative Law Judge (ALJ) hearing, followed by a review from the Medicare Appeals Council (MAC). The final level of appeal is judicial review in a federal district court. To initiate an appeal, review the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) for the reason for denial and instructions on how to proceed. Gathering supporting medical documentation from healthcare providers and adhering to strict filing deadlines at each stage are crucial for a successful appeal. For an ALJ hearing, the amount in controversy must meet a certain threshold, and for judicial review, it is $1,900 for 2025.