You’ve heard about these problems:
My back hurts so bad I can’t straighten up.
My back pain is relentless. I can’t do anything.
I don’t know what to do to get relief from this back pain.
Maybe you’ve even experienced back pain.
Too many times, back pain is chronic, which meaning Medicare defines as lasting 12 weeks or longer.
Almost 50% of those aged 65 and over suffer from back pain. That’s probably because so many medical conditions can cause the issue. The more common ones include:
- Degenerative disk disease
- Osteoarthritis
- Obesity
- Osteoporosis
- Spinal stenosis, and
- Spinal fractures.
Some of the first recommendations for dealing with chronic back pain are walking, swimming, exercise routines, back braces; all safe, cheap, and sometimes effective options. When those measures don’t provide adequate relief, it’s time to move into prescribed treatments. That’s where Medicare enters the picture.
Part D, Prescription Drug Coverage
Medicare coverage begins with prescription medications; that brings in Part D drug plans. There are many different categories of drugs that treat back pain and the choice depends on the situation. Here are five of the more common groups.
- Nonsteroidal anti-inflammatory drugs (NSAID) are often the first drug tried.
- Muscle relaxants help relieve spams.
- Anti-depressants may work for nerve-related pain.
- Topical medications provide localized relief.
- Opioids are reserved for severe pain but they come with the risk of addiction. (A study in the Journal of Pain Medicine found that almost 55% of older adults with an opioid diagnosis suffered from low back pain.)
Not every drug plan will cover every medication and a plan may require prior authorization.
If a new drug is under consideration, check the Medicare Plan Finder or with the drug plan to determine whether it’s covered, the cost and any restrictions.
Medicare Part B, Outpatient Services
Part B will pay for medically necessary services that meet accepted standards of medical practice to diagnose and treat a medical condition (illness or injury). That means the treatment must be supported by a diagnosis, is appropriate for that diagnosis, and is recognized as a medical treatment.
How Medicare deals with back pain can vary a bit based on the coverage you have.
- With Original Medicare, you are responsible for the annual Part B deductible, $257 in 2025, and then a 20% coinsurance for visits or treatments, which any Medicare supplement plan (Medigap policy) will cover. There are no prior authorization requirements for these back treatments. The medical practitioners must be Medicare-certified and accept Medicare assignment, and the services must meet Medicare criteria.
- Those who elected Medicare Advantage are responsible for the annual health plan deductible (which many plans don’t have) and cost sharing, which is usually a per-visit or treatment copayment. It is best to choose in-network providers. Some plans will require a referral and just about every plan will require prior authorization, which can limit the number of treatments or deny care entirely.
Here are four frequently prescribed procedures for treatment of low back pain.
1. Physical therapy: Therapeutic exercises, performed by a physical therapist and incorporated into a home program, help manage pain, and improve flexibility and mobility. PT can also help with any adaptative equipment, such as a cane or walker.
Medicare no longer has a cap or limit on how much it pays for PT in one year.
2. Chiropractic services: Treatments aim to adjust misalignments in the spine that can cause back pain and limited range of motion. Medicare covers chiropractic services for one reason only: manual manipulation of the spine to treat subluxation: when one or more spinal vertebrae are out of alignment as documented by an X-ray. However, the X-ray will have to be done somewhere else since Medicare does not pay for X-rays or tests that are ordered, performed or interpreted by the chiropractor.
There is no limit on the number of visits as long as the treatments are leading to improvement of function. Once the spine has been realigned, Medicare coverage ceases.
Medicare Advantage plans may cover chiropractic care for other reasons, such as joint pain, headaches, or stress relief.
3. Acupuncture: This is a treatment in which practitioners stimulate specific points on the body, most often by inserting thin needles through the skin. Five years ago, Medicare started covering all types of acupuncture, including dry needling as an alternative to opioid medications for low back pain. Here’s three things to know.
- To qualify, a person must have had chronic low back pain for 12 weeks or longer with no systemic cause and pain that is not associated with surgery.
- Medicare covers up to 12 sessions in 90 days, with up to eight additional sessions for those who demonstrate improvement.
- Treatments must be administered by a doctor or a physician’s assistant, nurse practitioner, or health care professional with a master’s or doctorate level training in acupuncture and a state license to practice acupuncture.
Medicare Advantage plans may cover acupuncture for other conditions.
4. Epidural injections: This non-surgical treatment is commonly used to manage radicular pain or pain that radiates along the path of a spinal nerve. Approximately 9% to 25% of people describe having low back pain with pain traveling down to below the knee.
The treatment involves injection of solution containing corticosteroids and/or anesthetic into the epidural space (inside the vertebral canal but outside the spinal cord). The corticosteroids can significantly reduce inflammation around an irritated nerve that is causing back and leg pain.
Medicare has very specific criteria but here are some important (but not all-inclusive) points about coverage criteria for epidural injections.
- History, physical examination, and X-rays support radicular pain.
- Radicular pain has lasted at least four weeks and is severe enough to have an impact on quality of life or function
- The individual cannot tolerate conservative or noninvasive treatments, and
- There is a limit of four sessions per spinal region in a 12-month period.
(Find the complete Local Coverage Determination here.)
A patient once told me he believed Ralph Nader (Boomers remember him) would have rejected the design of the back. We can do so many things to keep our backs healthy and happy but because chronic pain increases with age, we may not always succeed. That’s when we may need to seek medical help so it’s good to know Medicare’s role.
Read the full article here
